3/23/2020 1 Understanding Child Abuse and Its Long- Term Implications Marci Mechtel DNP, MSN, RN, ACCNS-P Grand Rounds March 25, 2020 Learner Outcome • At the end of the presentation, Rural health professionals (providers, nursing, and social work) will acquire – Identifying child abuse and recognize their role in prevention, treatment and reporting. – Understand potential of long‐ term complications as an Adverse Childhood Event. http://fijisun.com.fj/2015/01/03/500‐ cases‐of‐child‐abuse/ 1 2
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Understanding Child Abuse and Its Long-Term Implications
Marci Mechtel DNP, MSN, RN, ACCNS-P
Grand Rounds
March 25, 2020
Learner Outcome
• At the end of the presentation, Rural health professionals (providers, nursing, and social work) will acquire
– Identifying child abuse and recognize their role in prevention, treatment and reporting.
– Understand potential of long‐term complications as an Adverse Childhood Event.
• Assessment GCS, pupils, fontanel, and muscle tone
• Prompt treatment is needed
• Prevention is key due to high fatality rate
https://prezi.com/scrrtxh‐zl5k/tkm‐child‐abuse/
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Neglect 9,11
• Definition
• Highest incidence of maltreatment
• May involve physical, medical, educational, or emotional
• Signs of neglect http://wallpaperfolder.com/wallpapers/child+abuse
Medical Child Abuse11,13Munchausen Syndrome by Proxy
• Be suspicious for any complaints do not fit a particular illness, fail to resolve, or evolve in another illness.
• Symptoms are only seen by caregiver
• Low incidence 0.5‐2/100,000 children and often goes unrecognized
• Highest in 14 month to 2.7 years‐old.
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Emotional Abuse 9,11,14
• Definition
• Assessment
• Incidence 8‐9% in females and 4% in males
• Very difficult to prove and may need evidence of harm to child
• Often present with other types of maltreatmenthttp://wallpaperfolder.com/wallpapers/child+abuse
Sexual Abuse 9,11
• Definition
• Coercion to maintain silence
• Concern for STI and pregnancy
• Megan’s Law
• Sex Trafficinghttp://wallpaperfolder.com/wallpapers/child+abuse
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Long‐term Consequences of Abuse6,15
• Factors to consider
• Physical consequences
– Abusive head trauma
• Psychological
• Costs
What are Adverse Childhood Experiences17‐20
• Abuse (physical, sexual, psychological, and neglect)
• Household dysfunction (father absence, mental illness, violence against a caregiver, substance abuse, and incarceration)
• Newer literature also identifies extreme economic adversity, bullying, school violence, traumatic loss of a loved one, serious accident, life‐threatening childhood illness/injury, chronic childhood illness, natural disasters, refugee camps, and terrorism(
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How ACEs Impact the Life Span17,18, 21,22
• 10 risk behaviors and 7 health issues
• Mental health issues, multiple sexual partners, STIs, smoking, and alcoholism Leads to early alcohol use, tobacco, illicit drugs, suicide, adverse pregnancy outcomes
• Increased odds for binge drinking, heavy drinking, smoking, risky HIV behavior, diabetes, myocardial infarction, coronary heart disease, stroke, depression, and disabilities caused by health
(Felitti et al., 1998)
How Do ACEs Impact Healthcare20,23,24
• Overall reported health
• Use of healthcare services
• Primary, Secondary, and Tertiary Prevention
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Interdisciplinary Plan of Care• Laboratory tests
– Bone health
– Hematologic concerns
– CMP
– Urinalysis
– Toxicology screen
• Diagnostic tests
– Skeletal survey
– Abdominal x‐ray
– Head, chest, and abdominal CT as appropriate.
• Retinal exam in those with suspected AHT
• Management of any injuries
• Consult with Social Work, psychiatry, Child Protective Services
Interdisciplinary Plan of Care9,16
•Goals of care are to
–Protect child from further abuse
–Support child
–Support family
–Prevent abuse from occurring
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Reporting Process: Michigan
• As a mandated reported if you suspect any type of abuse or neglect you can make a report by
– Calling 855‐444‐3911
– Followed up with the filing of a DHS‐3200
• Child Protective Services then investigates
Case Study• Hillary is the 3‐year‐old you see in your office. Her mother told you that Hillary fell from a swing in the backyard. Hillary has a broken forearm, a broken rib, and multiple bruises on her chest and back. You notice in her chart Hillary was seen in the ER a month ago for a burn on the palm of her hand. When you mention to her mother that Hillary’s injuries seem extreme for a simple fall Her mother tells you, “Hillary isn’t pretty. I guess she’s also clumsy.”
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Hillary
• What do you suspect?
• How would you assess?
• What additional information is needed?
• What is your plan?
State and National Resources
• Society of Pediatric Nursing
• American Academy of Pediatrics
• National Association of Children’s Hospital and Related Institutions
• Centers for Disease Control and Prevention
• Human Trafficking
• Child Sex Trafficking in Michigan
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References1. U.S. Department of Health & Human Services. (2014).Child maltreatment. Retrieved
2. U.S. Department of Health & Human Services. (2018).Child maltreatment. Retrieved from: https://www.acf.hhs.gov/cb/resource/child‐maltreatment‐2018
3. Michigan Department of Human Services. (2014). Children’s Protective Services 2014 trend reporting summary. Retrieved from: http://www.michigan.gov/mdhhs/0,5885,7‐339‐73971_7119_50648‐‐‐,00.html.
4. Tanner, K. (2016, April 8). Child abuse and neglect in Michigan at record levels. Detroit Free Press. Retrieved from: http://www.freep.com/story/opinion/contributors/raw‐data/2016/04/08/child‐abuse‐and‐neglect‐michigan‐record‐levels/82713166/.
5. U.S. Department of Health & Human Services. (2014). Child Welfare Outcomes 2009‐2012: Report to Congress. Retrieved from: http://www.acf.hhs.gov/cb/resource/cwo‐09‐12.
6. Centers for Disease Control and Prevention. (2014). Understanding child maltreatment. Retrieved from: http://www.cdc.gov/violenceprevention/pdf/understanding‐cm‐factsheet.pdf.
References7. Hibbard, R.A., & Desch, L.W. (2011). Maltreatment of children with
disabilities. Pediatrics, 127(5), e1367.
8. Christian, C.W. (2015). The evaluation of suspected child physical abuse. Pediatrics, 135(5), e1337‐1354. doi: 10.1542/peds.2015‐0356.
9. Child Welfare Information Gateway. (2013, July). What is child abuse and neglect? Recognizing the signs and symptoms. Retrieved from: https://www.childwelfare.gov/pubs/factsheets/whatiscan/.
10. Flaherty, E.G., Perez‐Rossello, J.M., Levine, M.A., & Hennrikus, W.L. (2014). Evaluating children with fractures for child physical abuse. Pediatrics, 133(2), 477‐489. doi: 10.1542/peds.2013‐3793.
11. Carter, B.M. (2018). Health problems of early childhood. In M. Hockenberry D. Wilson, & C.C. Rogers (Eds.), Wong’s Nursing care of infants and children (11th ed. pp 440‐459). St. Louis, MO: Elsevier Mosby.
12. Egge, M.K., & Stewart, S.T. (2014). Physical Abuse. In C.D. Berkowitz (Ed.), Pediatrics: A primary care approach. (5th ed.). Elk Grove Village, IL: American Academy of Pediatrics.
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References13. Flaherty, E.G., & MacMillan, H.L. (2013). Caregiver‐fabricated illness in a child: A
manifestation of child maltreatment. Pediatrics, 132(3), 590‐ 597. doi: 10.1542/peds.2013‐2045.
14. Hibbard, R., Barlow, J., & MacMillen, H. (2012). Psychological maltreatment. Pediatrics, 130(2), 72–378. doi:10.1542/peds.2012‐1552
15. Child Welfare Information Gateway. (2013, July). Long‐term consequences of abuse and neglect. Retrieved from: https://www.childwelfare.gov/pubpdfs/long_term_consequences.pdf.
16. Child Welfare Information Gateway (2013, July). Preventing child abuse and neglect. Retrieved from: https://www.childwelfare.gov/pubpdfs/preventingcan.pdf.
17. Campbell, J.A., Walker, R.J., & Egede, L.E. (2016). Associations between adverse childhood experiences, high‐risk behaviors, and morbidity in adulthood. Journal of Preventative Medicine, 50(3), 344‐352.
18. Dube, S.R., Felitti, V.J., Dong, M., Giles, W.H., & Anda, R.F.(2003). The impact of adverse childhood experiences on health problems: Evidence from foub birth cohorts dating back to 1900. Preventative medicine, 37, 268‐277.
19. Felitti, V.J., Anda, R.F., Nordenberg, D. Williamson, D.F., Spitz, A.M., Edwards, V...Marks, J.S.(1998). Relationship of childhood abuse and household disfunction to many of the leading causes of death in adults. American Journal of Preventative Medicine, 14(4), 245‐258.
References20. Reichman, N.E., Corman, H., Noonan K., & Jiménez, M.E. (in press). Infant
health and future childhood adversity. Maternal and Child Health Journal.doi.org/10.1007/s10995‐017‐2418‐5.
21. Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz,A…Peek‐Asa, C.(2015). Adverse childhood experiences and trauma informed care: The future of health care. Pediatric Research, 79(1), 227‐233.
22. Substance Abuse and Mental Health Services Administration. (2015, June 8).Recognizing and treating child traumatic stress. Retrieved from: https://www.samhsa.gov/child‐trauma/recognizing‐and‐treating‐child‐traumatic‐stress.
23. Chartier, M.J. Walker, J.R., & Naimark, B.(2010). Separate and cumulative effects of adverse childhood experiences in predicating adult health and health care utilization. Child Abuse and Neglect, 34, 454‐464.
24. Kalmakis, K.A., & Chandler, G.E.(2015). Health consequences of adverse childhood experiences: A systematic review. Journal of the American Association of Nurse Practitioners, 27(8), 457‐465.