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A skilled, sensitive, diplomatic interview is fundamental to management. Guidelines include:
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a relaxed, non-judgmental approach
sensitivity to all people involved
appropriate questions—open-ended, not leading
using verbatim quotes from the child where possible and waiting silently for a reaction
recording notes carefully
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Physical abuse should be suspected, especially in a child aged under 2 years, if certain physical or behavioural indicators in either the child or the parents are present. Inflammation, bruising, abrasions and lacerations are the most common presentations of the physically abused child, with equal incidence in boys and girls. As well as the consequences of the physical injuries, victims of physical abuse are more likely to develop a variety of behavioural and functional problems including conduct disorders, physically aggressive behaviour (e.g. become bullies), poor academic performance and decreased cognitive functioning. Children suffering traumatic brain injuries from physical abuse (e.g. hitting head or shaking) are at risk of disabilities including ADHD, seizures, spasticity, blindness, paralysis and developmental delay.
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Parents and carers can tend to misinterpret normal child behaviours (e.g. crying and tantrums) and respond to them inappropriately. A vigilant GP can actually help prevent abuse by providing ‘anticipatory guidance’ to parents on normal child behaviour, educating them on appropriate responses to behaviours, and offering themselves as a resource to which they can turn if the child’s behaviour becomes unmanageable or overwhelming.
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Physical abuse indicators
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Accidental injuries such as bruises or fractures are common in children, but tend to follow certain patterns. A GP should be aware of cases where the injury or injuries suggest a non-accidental cause is possible, when the history doesn’t match up with the injury or developmental age of the child, or when the behaviour of the parent and/or child is suggestive of non-accidental injury.
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Bruises are commonly found on the front of the body over bony prominences (e.g. forehead in toddlers, knees and shins in older children). Suspicious bruises include:
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finger-shaped bruises (e.g. thumb grip marks)
multiple bruises/welts of different ages (the colour of a bruise doesn’t reliably indicate when it occurred)
bruises in premobile children
bruises away from bony prominences—face, scalp, neck, buttocks (see FIG. 95.2), genitalia, earlobes, behind the ears
abdominal bruising (consider damage to internal organs, including organ rupture)
multiple bruises of uniform shape
multiple bruises in clusters
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a scald of uniform depth, sparing flexures, uniform burn line demarcation, bilateral and no splash marks (suggests forced immersion)
unusual position (e.g. back of hand, genitals)
cigarette butt-type burns
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metaphyseal fractures of the proximal humerus and proximal or distal tibia are highly suggestive
other fractures commonly non-accidental: rib (especially posterior), clavicle, vertebral body, sternum, scapula
multiple, especially bilateral
complex or multiple skull fractures
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Shaking and brain injury
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Shaking a baby is a critically dangerous thing to do, a danger often underestimated by perpetrators. The relatively large head size and weak neck muscles can easily lead to serious injury. Suspicion of traumatic brain injury should be raised when there is:
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unexplained encephalopathy
unexplained vomiting, irritability and apnoeas
altered states of consciousness
neurological symptoms and signs
torn frenulum or retinal damage
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Unexplained injury
Different explanations offered
Vague or changing history
Injury unlikely to have occurred in manner stated
Unreasonable delays between injury and presentation
Presentation inconsistent with child’s developmental capabilities
Evidence of neglect (clues include failure to thrive, dental caries, severe nappy rash, poor wound care)
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Remember Munchausen syndrome by proxy.
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Behavioural indicators
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Wariness of adult contacts
Inappropriate clothing (e.g. long sleeves on a hot day)
Apprehension when other children cry or shout
Behavioural extremes
Fear of parents
Afraid to go home
Child reports injury by parents or gives inappropriate explanation of injury
Excessive compliance
Extreme wariness
Attaches too readily to strangers
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If suspected or disclosed, a thorough assessment, with detailed documentation (including measurement and photography of bruises/other injuries) of findings should be undertaken. A detailed history and thorough examination of all areas of the body is required. In a general practice setting, getting help with this difficult situation would often be useful. Discussing (immediately) with colleagues or child protection authorities is advisable, with the safety of the child (and other cohabiting children) being ensured at all stages. Verbatim comments should be written down and, if possible, information gathered from other sources or witnesses.
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The family doctor should diplomatically confront the parents and/or carers and always act in the best interests of the child. Offer to help the family. An approach would be to say, ‘I am very concerned about your child’s injuries as they don’t add up—these injuries are not usually caused by what I’m told has been the cause. I will therefore seek assistance—it is my legal obligation. My duty is to help you and, especially, your child.’
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Acquiring essential help
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Psychosocial assessment of child and family: involves social worker and multidisciplinary assessment
Admission to hospital: for moderate and severe injuries
Investigations done in conjunction with specialists
Case conference (where appropriate)
Mandatory reporting: notify child protection authorities
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Behavioural indicators
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Extremely low self-esteem.
Compliant, passive, withdrawn, tearful and/or apathetic behaviour.
Aggressive or demanding behaviour.
Anxiety.
Serious difficulties with peers and/or adult relations.
Delayed or distorted speech.
Regressive behaviour (e.g. soiling).
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Poor parenting or neglect occurs in at least 5% of children under 5 years.10
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Consistent hunger.
Failure to thrive, or malnutrition.
Poor hygiene.
Inappropriate clothing.
Consistent lack of supervision.
Unattended physical problems or medical needs.
Abandonment.
Dangerous health or dietary practices.
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Behavioural indicators
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Stealing food.
Extending stays at school.
Consistent fatigue, listlessness or falling asleep in class.
Alcohol or drug abuse.
Child states there is no caregiver.
Aggressive or inappropriate behaviour.
Isolation from peer group.
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Only 6% of child sexual abuse is by strangers. Most are known by parents and child; that is, familiar people in familiar environments, especially within the family.
A child may disclose up to 12 times before they are believed (listen for hints).
Most (but not all) of the adults who sexually abuse are men.
Boys are assaulted less commonly than girls, but are less likely to disclose if they are assaulted.
Adolescents are perpetrators in at least 20% of cases.
Child sexual abuse is usually about power rather than sexual gratification.
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Sexual abuse presents in three main ways:
Allegations by the child or an adult
Injuries to the genitalia or anus
Suspicious presentations, especially:
— genital infection (see FIG. 95.3)
— recurrent urinary infection
— unexplained behavioural changes/psychological disorders
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Clinical indicators that may suggest child sexual abuse are presented in TABLE 95.1.
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Ideally, the child should be assessed by experienced medical officers at the regional sexual assault service, so the temptation for the inexperienced GP to have a quick look should be resisted. For the practitioner having to assess the problem, a complete medical and social history, including a behavioural history, should be obtained prior to examination.
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The child’s history must be obtained carefully, honestly, patiently and objectively, without leading the child. The history is more important than the physical findings as there are no abnormal physical findings in many confessed cases.
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A parent or legal guardian must give informed consent before the child is physically examined. It is recommended that the physical examination of any child suspected of being sexually abused is performed by a paediatrician or forensic physician experienced in the area of sexual abuse.
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Point of caution:
Perianal erythema due to streptococcal infection (GABHS) (see FIG 95.4) or threadworms and non-specific vulvovaginitis (see CHAPTER 107) can be misinterpreted as sexual abuse.
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It is important to realise that the child will be in crisis. Children are trapped into the secrecy of sexual abuse, often by a trusted adult, through powerful threats of the consequences of disclosure. They are given the great responsibility of keeping the secret and holding the family together or disclosing the secret and disrupting the family. A crisis occurs when these threats become reality.
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It is important to act responsibly in the best interests of the child. When we encounter real or suspected child abuse, immediate action is necessary. The child needs an advocate to act on its behalf and our intervention actions may have to override our relationship with the family.
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Never attempt to solve the problem alone.
Do not attempt confrontation and counselling in isolation (unless under exceptional circumstances).
Seek advice from experts (only a telephone call away).
Avoid telling the alleged perpetrator what the child has said.
Refer to a child sexual assault centre or Protective Services Unit where an experienced team can take the serious responsibility for the problem.
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Acknowledge the child’s fear and perhaps guilt.
Assure the child it is not his or her fault.
Tell the child you will help.
Obtain the child’s trust.
Tell the child it has happened to other children and you have helped them.