Jonathan Glauser
CHILD ABUSE
More than 1 million cases of child maltreatment are recorded annually in the United States. Two-thirds of victims of physical abuse are <3 years old.
Child maltreatment includes physical abuse, sexual abuse, emotional abuse, supervisional neglect, parental substance abuse, and Munchausen syndrome by proxy.
CLINICAL FEATURES
Children with failure to thrive are generally under the age of 3 years.
They may present with skin infections, severe diaper dermatitis, or acute gastroenteritis.
Weight tends to be more affected than length, with body mass index under the fifth percentile. Infants may have little subcutaneous tissue, protruding ribs, or occipital alopecia from lying on their back all day.
They are wide eyed, wary, and difficult to console.
They may have increased muscle tone in their lower extremities.
Weight gain in the hospital is thought to be diagnostic of failure to thrive.
Children over the age of 2 years with environmental neglect are termed psychosocial dwarfs.
Their short stature is more prominent than their low weight.
They tend to be hyperactive with unintelligible or delayed speech and bizarre and voracious appetite.
Physical abuse is suggested by a history that is incon sistent with the nature of the injuries.
For example, a fall off of a bed should not cause a femur fracture.
Children under the age of 6 months cannot induce accidents or ingest drugs or poisons, as another example.
The history of the event given by the caretaker may keep changing, or may be different from that given by the child.
The following findings suggest physical abuse:
1. Bruises over multiple areas.
2. Bites with an intercanine diameter >3 cm, since these must be inflicted by an adult.
3. Lacerations of the frenulum or oral mucosa, from force-feeding.
4. Burns of an entire hand or foot, or burns of the buttocks or genitalia from toilet training punishment.
5. Cigarette burns, with approximately 5-mm scab-covered injuries.
6. Spiral fractures caused by twisting of long bones.
7. Metaphyseal chip fractures.
8. Periosteal elevation from new bone formation at sites of previous microfractures.
9. Multiple fractures at different stages of healing.
10. Fractures at unusual sites such as lateral clavicle, ribs, and sternum.
11. Vomiting, irritability, seizures, change in mental status, or apnea from intracranial hemorrhage (shaken baby syndrome). Retinal hemorrhages on funduscopic examination may be present.
12. Vomiting, abdominal pain, and tenderness with diminished bowel sounds or abdominal disten-tion may be due to a duodenal hematoma, as evidenced by a “double-bubble” sign on abdominal radiographs.
Munchausen syndrome by proxy is a synonym for medical child abuse. A parent fabricates illness in a child in order to secure prolonged contact with health care providers.
Complaints may be numerous, including seizures, bleeding, fever, altered mental status, vomiting, or rash. Agents such as ipecac or warfarin may have been given to precipitate these complaints.
Parents typically encourage more diagnostic tests, and are happy if they are positive.
Sexual abuse is suggested with complaints referable to the anogenital area, such as bleeding, discharge, or the presence of a sexually transmitted disease.
Clefts or concavities in the hymen typically present in the 6 o’clock position.
DIAGNOSIS AND DIFFERENTIAL
Any serious injury in a child under the age of 5 years should be viewed with suspicion.
Parents and caregivers may appear to be under the influence of drugs or alcohol. They may refuse diagnostic studies.
Victims of neglect may appear dirty, may be improperly clothed, and may be unimmunized.
Victims of child abuse may seem overly compliant with painful medical procedures.
They may be overly protective of the abusing parent, or appear to be overly affectionate to medical staff.
A skeletal survey of the long bones may be performed to detect any evidence of physical abuse.
Laboratory workup may include a CBC and PT/PTT and PFA-100 screen for coagulation abnormalities.
Careful inspection of the genital area is generally sufficient to establish genital injury.
Speculum examination in the preadolescent is generally not needed unless perforating vaginal trauma is suspected.
Children can be examined in a frog-leg position; stirrups are usually unnecessary.
Colposcopy and toluidine blue may detect subtle acute injuries but are generally not available.
The diameter of the hymeneal orifice may not be indicative of prior vaginal penetration.
Fissures, abrasions, thickened perianal folds, lichenified perianal skin, or decreased anal tone may result from acute or chronic sodomy.
Absence of physical findings does not rule out abuse.
Laboratory testing for sexual abuse should include cultures of the throat, vagina, and rectum for gonorrhea and chlamydia.
Rapid antigen assays are not considered reliable forensic evidence in prepubescent children.
Syphilis testing should be performed if there is clinical suspicion, if there is a high incidence in the community, or if the assailant has a history of syphilis.
If there is a reason to suspect HIV and appropriate counseling is available, testing should be done.
EMERGENCY CARE AND DISPOSITION
Infants suspected of suffering from failure to thrive should be admitted to the hospital.
Every state requires that suspected cases of child abuse be reported.
The law protects physicians from legal retaliation by parents.
Children with suspected Munchausen syndrome by proxy should be admitted for social and psychological evaluation.
ELDER ABUSE
Elder abuse is an act or omission resulting in harm to the health or welfare of an elderly person, and affects 3% of the US elderly population.
This may entail neglect, such as deprivation of food, clothing, shelter or medical care, physical or sexual abuse, or abandonment of an elder in a home, hospital, or public location such as a shopping mall.
Unique to this age group is financial exploitation: use of pensions or Social Security checks for personal gain, forcible transfer of property, or changing an elderly person’s will.
CLINICAL FEATURES
Physical abuse is the most easily recognized form of elder abuse, although chemical restraint such as intentional overmedication may be subtle.
Caregiver neglect, defined as failure of a caregiver to provide basic care, goods, and services such as clothing and shelter, accounts for the majority of cases of elder abuse.
Financial abuse is the second commonest form of abuse, and occurs when family members take control of or steal assets, checks, or pensions for personal gain.
Emotional abuse entails inflicting anguish, emotional pain, or distress.
Verbal threats, social isolation, and harassment can contribute to depression and other mental health problems.
Self-neglect includes those behaviors of an elderly person that threaten his or her own safety: failure to provide adequate food, medical care, hygiene, clothing, or shelter.
DIAGNOSIS AND DIFFERENTIAL
Risk factors for elder abuse may be associated with caregivers/perpetrators or with the elders. Patient characteristics include the following:
1. Cognitive impairment
2. Female sex
3. Physical dependency
4. Alcohol abuse
5. Developmental disability, special medical or psychiatric needs
6. Lack of social support
7. Limited experience managing finances
Risk factors for perpetrators of abuse include the following:
1. History of violence within or outside of the family.
2. Excessive dependence on the elder for financial support.
3. History of mental illness or substance abuse.
To make the diagnosis, potential sufferers of abuse should be interviewed in private.
Screening questions have been developed for elder abuse, querying whether anyone has touched or hurt them, forced them to do things, taken something of theirs without asking, threatened them, or made them feel afraid.
Caretakers may give a conflicting report of an injury or illness.
The patient may appear fearful of his or her companion.
The caretaker may seem indifferent or angry toward the patient, or may be overly concerned with costs of treatment needed by the patient.
The following are suggestive on physical examination for abuse:
1. Bruising or trauma
2. Poor general appearance and hygiene
3. Malnutrition and dehydration
4. Contusions and lacerations to normally protected areas of the body: inner thighs, mastoid, palms, soles, buttocks
5. Unusual burns or multiple burns in different stages of healing
6. Rope or restraint marks on ankles or wrists
7. Spiral fractures of long bones
8. Midshaft ulnar (nightstick) fractures from attempts to shield blows
9. Multiple deep/uncared-for ulcers
10. Poor personal hygiene, inappropriate or soiled clothing
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Elder abuse is widely underreported and underrecognized. Treatment entails three key components:
1. Addressing medical and psychosocial needs
2. Ensuring patient safety
3. Compliance with local reporting requirements
Medical problems and injuries may be best managed with hospital admission.
Elders left in the same position for an extended period of time should be screened for rhabdomyolysis.
All 50 states have reporting requirements for elder abuse and neglect. Adult protective services should be notified.
Patients in immediate danger should be hospitalized.
If neglect is unintentional, education of the caregiver may be all that is needed.
Requirements for reporting within one’s practice area are available at www.nceaaoa.gov
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 290, “Child Abuse and Neglect,” by Carol D. Berkowitz, and Chapter 293, “Abuse of the Elderly and Impaired,” by Frederic M. Hustey and Jonathan Glauser.