CHILD ABUSE AND NEGLECT

Child abuse is maltreatment of children or adolescents by parents, guardians, or other caregivers. Early recognition is very important for prompt intervention.

Most child abusers (90%) are related caretakers who tend to be lonely, unhappy, angry and under heavy stress. Many of them experienced child abuse of one form of another during their own childhood.

Some Characteristics of Abused children

  • Negativity
  • Difficult temperament
  • Offensive behaviour
  • Disability.

Types of child abuse

  1. Physical abuse (non-accidental trauma):
    • This is the commonest form of child abuse.
    • It manifests as physical injuries that include bruises, burns, head injuries, and bone fractures. Their severity can range from minor bruises to fatal injuries.
  2. Emotional abuse:
    • This type of abuse is characterized by intentional verbal acts, criticisms, and lack of nurturing.
    • This type is very difficult to prove.
  3. Nutritional neglect or deliberate underfeeding: This is associated with failure to
    thrive.
  4. Sexual abuse:
    • This usually occurs with family members and is the most overlooked (or under reported) form of abuse.
    • Types of sexual abuse include
      • Molestation
      • Sexual intercourse
      • Rape.
  5. Others: These include intentional drugging (or poisoning) or neglect of medical care.

CLINICAL PRESENTATION

  • Physical abuse may manifest as unexplained inconsistent injuries and delay in seeking medical help for the injuries.
  • Sexual abuse may remain concealed for fear of reprisal from the perpetrator; often the victim (in this case the abused child) does not know what to do or where and how and to whom to report.
  • Most victims report to a health facility due to
    • Acute stress
    • Vaginal bleeding
    • STIs
    • UTI
    • Enuresis
    • Encompresis (faecal incontinence in absence of organic defect)
    • Pregnancy.
  • Children with nutritional neglect present with;
    • Failure to thrive
    • Poor hygiene
    • Delayed immunizations
    • Delayed development in speech
    • Delayed Mental status and social interaction.
  • Most abused children are shy with expressionless faces and tend to avoid eye-to-eye contact.

INVESTIGATIONS

For children who are suspected to be abused, the following are recommended:

  • Thorough history and examination for all types of abuse, indicating who accompanies the child to the health facility.
  • In physical abuse, total skeletal survey (x-ray – may find fractures at various healing stages) is recommended.
  • Sexual abuse: Examine for sperms, acid phosphatase and infections, e.g., gonorrhoea. Rape cases may require examination under GA to determine the type and extent of genital injury.
  • Nutritional neglect: Must rule out all other causes of failure to thrive.

MANAGEMENT

Admit the child for the following reasons:

  • The diagnosis may be unclear, admission may be important for the child because of consideration for immediate safety, or the state of the child might require medical or surgical intervention.
  • The need to remove the child from the source of the abuse in order to protect the child until the evaluation of the family with respect to the safety of the child is completed.
  • The needs of the perpetrator for psychiatric evaluation and care.
  • The need to involve the police and the social worker for more effective management of the child.
    For children who experience rape or sodomy, the following needs to be done:
  • Sedate as necessary with phenobarbitone 5–8mg/kg/day or diazepam at 0.1– 0.25mg TDS.
  • Give prophylaxis for HIV/AIDS (see under HIV/AIDS).
  • Carry out surgical repair of injuries (sphincter injury, which may require colostomy with secondary repair).
  • Counsel the child.

PREVENTION

  • Health workers should have a high index of suspicion on the likelihood of abuse.
  • Older children should be encouraged not to keep secrets and to refuse any enticement to have what could be sexual abuse.
  • Children who are in a high-risk situation should be removed from that environment and not left there.
  • Referral for these children is necessary for long-term psychological and psychiatric care