Child Maltreatment – a Global Issue

Estimates of prevalence and incidence vary widely, depending on the country and the method of research used, particularly as there are no standardized statistics. In the United Kingdom, the National Society for the Prevention of Cruelty to Children (NSPCC) estimated that more than 57,000 children were in need of child protection services in 2015. In 2014, there were 42 deaths by assault or undetermined intent of children age 28 days to 14 years in the UK and 62 cases of homicide [4].

UNICEF estimates that violence took the lives of around 54,000 adolescent girls between the ages of 10 and 19, in 2012, making it the second leading cause of death among this population (Figure 4.1) [5].

Figure 4.1 Hidden in Plain Sight: A statistical analysis of violence against children, UNICEF, New York, 2014.

Source: World Health Organization, Global Health Estimates (GHE) Summary Tables: Deaths by cause, age, sex and region, 2012, WHO, Geneva, 2014, recalculated by UNICEF.

The global community has addressed the issues in one of the sustainable development goals launched in January 2016, which outline the global priorities for the next 15 years. Goal 5, the goal for gender equality, outlines an aspiration to eliminate all forms of violence against women and girls such as trafficking and exploitation as well as harmful practices such as forced marriage and FGM.

Child Maltreatment – Why It Is Important

Gynecologists are in a unique position to recognize the signs and symptoms of child abuse at different times during the patient’s management. Talking to a patient confidentially gives the child or young person the opportunity to disclose maltreatment. It is a recognized professional duty to identify and report child abuse in most industrialized nations; there is a mandatory duty to report child abuse in some states in the United States, Canada, Australia, Brazil, South Africa, and states in the European Union including Sweden.

Studies have shown that children who experience maltreatment are also at increased risk of short and long term physical and mental health conditions that include the following:

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  Unintended pregnancy, sexual transmitted diseases, sexual exploitation

  
  
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  Physical injury, for example, broken limbs, abusive head trauma resulting in death

  
  
• 
  

  Psychological effects, for example, depression, posttraumatic stress disorder, anxiety

  
  
• 
  

  Behavioral effects, for example, smoking, drug and alcohol misuse

  
  
• 
  

  Chronic disease, for example, heart disease, high blood pressure, and cancer

  
  
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  Poor early development, academic achievement, and social-emotional well-being

There are also societal consequences of child maltreatment. In the United States, abuse and neglect increase the likelihood of adult criminal behavior by 28 percent and violent crime by 30 percent [6]. Victims of abuse are also more likely to perpetuate the abuse cycle.

Recognizing Child Maltreatment and the Duty of the Pediatric and Adolescent Gynecologist

It is important that gynecologists have a clear idea of how to refer to local services when there is a suspicion or allegation of maltreatment. All areas will have local and national guidelines. Clinicians should also be up to date with basic training as suggested by their professional bodies.

A girl or young woman who is a victim of maltreatment may present in the outpatient clinic, when an in-patient, or in the emergency department (see Box 4.1) with a symptom and/or sign that may lead to a suspicion of maltreatment or there maybe a disclosure of an incidence of maltreatment including rape or exploitation. Remember to create an opportunity to speak to the child/young person alone. One way of doing this would be to say, “It is my usual practice to speak to children/young people on their own as part of my assessment.”

If another doctor is present, such as a trainee, then it is often less threatening to suggest one sees the parent while the other the child but in different rooms.

It is important to recognize that

1. 
   

   1. Several forms of abuse may coexist, for example, witnessing domestic violence and being subject to physical abuse and neglect.

   
   
2. 
   

   2. There maybe abuse in addition to the underlying condition being treated, for example, emotional abuse and intersex.

   
   
3. 
   

   3. There may be other coexisting diagnoses, e.g. sexual abuse and lichen sclerosis.

   
   
4. 
   

   4. There is often a distinctive cultural context, for example, corporal punishment or FGM [7].

Remember that it is not only the younger child who is vulnerable. The developmental trajectory of adolescents who are living in a wide social context gives many opportunities for harm [8]. They are vulnerable to

1. 
   

   1. Continuing maltreatment from childhood

   
   
2. 
   

   2. Sexual exploitation

   
   
3. 
   

   3. Cyberbullying

   
   
4. 
   

   4. Gangs and peer-on-peer abuse

   
   
5. 
   

   5. Forced marriage

   
   
6. 
   

   6. Intimate partner violence

Health care practitioners are often concerned about how to approach the topic of maltreatment with the family and are worried about provoking a negative or angry response from parents. some patients presenting to gynecologists will be suffering some form of maltreatment, so despite these fears ensure that the well-being of the child/young person is paramount [9].

If there is suspicion of maltreatment, refer to the professional with expertise in child protection. This might be a pediatric doctor or specialist nurse. In the UK, a named doctor or nurse is available for safeguarding who is available to discuss cases and offer advice [10]. In the United States, similarly the hospital may have a specialist child protection team or specialist doctor. In the United States, there is also a mandatory duty to report to child protective services and the Child Advocacy Center [11]. A child protection specialist will undertake a more comprehensive assessment. You can explain your concerns to the family as follows: “I would like to get to the bottom of what is going on with your child and so will refer to my pediatric colleagues for support.” If at any point there are concerns that the child is in an unsafe home environment, alert social services and if there is immediate danger the police.

Risk Factors in the Background History – Family and Social History

It is helpful to consider protective factors, which includes the child’s resilience (ability to overcome adversity), and vulnerability factors to understand why a particular child is susceptible to abuse, all of which may be elicited during the history. A helpful statement to use is, “It is my usual practice/local policy to ask all families a number of questions about their background to help me with the assessment.”

Despite challenging circumstances, parents may still have the capacity to give adequate care; for example, a mother with moderate depression may still be an excellent parent who prioritizes her child’s needs. Therefore questions relating to a family’s background should be approached sensitively and without judgment. Box 4.2 highlights some of the important factors to consider when child maltreatment is suspected.

Documentation

It is vital to keep clear, concise, and contemporaneous notes. These may be required for reports including witness statements for legal proceedings. Include the date, time, location, and persons present for each part of the consultation and who gave the history. Label body maps and diagrams to illustrate the location, dimensions, color, and texture of any marks identified on the skin, including birthmarks, as well as scars or bruising. Document, if known, with the cause of any marks and supplement with photographs if possible although the forensic examiner will usually do this.

A distinction should be made between observations and suspicions and interpretations in the notes. Where possible, it is useful to note down illustrative quotes, for example, “Mom always hits me on my back so my teacher can’t see the marks.”

Examination

If possible, extend the usual gynecological examination if there is a suspicion of maltreatment. This enables clear onward referral to the specialist.

Include the following if possible:

1. 
   

   – Height, weight, head circumference plotted on growth charts. (The child who is underweight or has stunted growth may lead to consideration or suspicion of neglect.)

   
   
2. 
   

   – General appearance: Is the child wearing clean appropriate clothing? Is there any dirt under the nails? Has the hair been washed?

   
   
3. 
   

   – General demeanor: Is the child withdrawn or scared? How is his or her interaction with the carer? Was the child cooperative?

   
   
4. 
   

   – Whole-body examination of skin, hair, mouth, teeth, nose, head, and scalp. Hidden areas such as the neck, back of ears, soles of feet should also be examined.

   
   
5. 
   

   – Systemic examination of cardiovascular, respiratory, and abdominal systems and other systems as indicated.

   
   
6. 
   

   – Pubertal stage.

   
   
7. 
   

   – Developmental milestones, cognitive ability – suspicion of learning difficulties: Did they follow your instructions? Did they understand your questions? Are they ambulant?

   
   
8. 
   

   – Note if any part of the examination was omitted and if so why.

Recognizing a Child with Physical Abuse

It is common for children to have bruises on their skin particularly if they are ambulant or of school-going age (Figure 4.2). A child who is or has been the victim of physical abuse may or may not present with visible physical signs on examination. However, injuries such as bruising (Figure 4.3), scars, bites, or burns on examination may arouse suspicion of maltreatment. Other features that may arouse suspicion are listed in Box 4.3. Figures 4.2 and 4.3 are body maps showing patterns of accidental and abusive bruising [12].

Figure 4.2 Body maps showing pattern of bruising in accidental injury

Figure 4.3 Body maps showing pattern found in abused children

Investigations and further management of physical abuse

Recognizing FII

The signs of FII include the following:

1. 
   

   – High level of anxiety from parent/carer and requests for repeat consultations

   
   
2. 
   

   – Parent requesting more investigations and treatment

   
   
3. 
   

   – No cause identified for presenting features

   
   
4. 
   

   – Exaggeration of symptoms, for example, profuse bleeding that is never observed

   
   
5. 
   

   – Many opinions sought

You may suspect child maltreatment, if features as listed in Box 4.3 are present e.g. unexplained bruising on the the inner thighs. As part of the further management, explain to the mother that a second opinion from Pediatric colleagues is in the child’s best interest.

As part of the complete assessment, investigations need to be arranged to rule out any medical causes of bruising or injury, such as Von Willebrand disease. Discuss with a hematologist if there is any family history of bleeding disorders.

First line investigations include

1. 
   

   – Full blood count, white cell count, hemoglobin, and platelet

   
   
2. 
   

   – Coagulation screen