Child abuse and mistreatment
Mistreatment of minors:
«all forms of physical and/or emotional mistreatment, sexual abuse, neglect or negligent treatment, as well as sexual or other exploitation, which result in actual or potential harm to the health, survival, development or dignity of the child, in scope of a relationship of responsibility, trust, or power.» WHO ( World Health Organization, 1999; 2002)
Child abuse and mistreatment
2
Mistreatment of minors
European report on preventing child mistreatment, OMS 2013: • 852 children under 15 die each year in Europe as victims of mistreatment (the highest rate is in children under 4) • 18 million children (13.4% of girls and 5.7% of boys) are victims of sexual abuse • 44 million (22.9% of children) are victims of physical violence • 29,6% are victims of psychological violence (55 million)
Child abuse and mistreatment
3
Frequency… …is not known, but certainly underestimated • • • • • • • • •
Lack of privacy Non-compliance with legal duties High number of patients in EDs Skepticism about the effectiveness of interventions Insufficient training of ED doctors (including pediatricians) Uncertainty in its delimitation, in the physical and psychic sphere Absence of trusting relationship with the child and his parents Psychological resistance to admitting a phenomenon considered aberrant Masking by the aggressors and family and also by the victim himself
Child abuse and mistreatment
4
Abuse The presence of at least one of the following conditions: 1. Pathology of care carelessness Discuria Overcure 2. Mistreatment properly said Physical Psychological 3. Sexual abuse
Child abuse and mistreatment
5
The experience in OPBG
The activity of detecting cases of unacknowledged abuse is very important.
“ CHILD PROTECTION AND DEVELOPMENTAL AGE” Child abuse and mistreatment
6
Screening indicators Risk factors for the protection of childhood and developmental age: • Medical history inconsistencies: history that does not explain the causes of the lesions or pathologies detected, history inconsistent on the cause of lesions, history not compatible with the clinical objectivity detected • Declaration (by the child’s carers) of a suspected abuse, domestic violence, harassment or sexual assault • Child exposed to drug use • History of previous abuse or domestic violence • Child in conditions of abandonment, or with parents whose parental responsibility is suspended • Serious physical neglect that causes pathological conditions of the minor (pathology of care)
Child abuse and mistreatment
7
Screening indicators Risk factors for the protection of childhood and developmental age: • Evident and serious lack of timely medical care and/or failure to comply with specifically recommended medical care, which is detrimental to the health of a minor • Unexplained bruising • Unexplained burns or burns involving more than 10% of body surface area, cigarette burn, genital burns • Evidence of multiple traumatic injuries that occurred at different times (polychronous injuries), not attributable to usual play-sports activities, especially if under 3 years of age • Fractures under one year of life with no consistent history • Drowning, violent mechanical asphyxiation • Precipitation
Child abuse and mistreatment
8
Child abuse and mistreatment
9
Child abuse and mistreatment
10
Child abuse and mistreatment
11
Care pathways in cases of suspected/ascertained abuse Send AG report REPORT: DETECTION/DIAGNOSIS
At the end of the Clinical Pathway
- Report procedure - Territory contacts
DEA pediatricians ent m e v l Invo cialists e of sp
UO/Services ent m e v l Invo cialists e of sp
UO/Services
TERRITORIAL SOCIAL SERVICES
Neuropsychiatry
- Screening application - Data collection in confirmed cases - SS OPBG involvement
12
Clinical path in which the use of all the necessary specialist professional figures must be envisaged: • to the most appropriate diagnostic procedure • to the best therapeutic treatment of lesions/pathologies • to the most effective taking charge of the abused minor for protective purposes All diagnostic activities shall obey to the principles of: • maximum hospitality • minimal invasiveness • rigorous verification of any differential diagnoses
Child abuse and mistreatment
13
On the door assessment
• AVPU • Presence of trauma and/or physical injury: ✓ Location (skin lesions in normally atypical locations, fractures in suspected locations, abdominal and thoracic trauma) ✓ Number (lesions on different areas of the body, multiple or multiform by type) ✓ Aspect (bruises, bites, lashes, burns, scars, etc.) ✓ History (of both skin lesions and fractures) • Overall appearance of the patient
Child abuse and mistreatment
14
State of hemoglobin degradation
Red/blu <5 days
Child abuse and mistreatment
Green/yellow 5/7 days
Brown >7 days
15
Head trauma
It represents the most frequent cause of mortality May manifest as subdural hematoma, skull fracture, intraocular hemorrhage, otorrhagia, or epistaxis
SHAKEN BABY SYNDROME It is consequent to the rapid acceleration or deceleration inflicted on the head with rupture of cerebral vessels and is frequently associated with retinal hemorrhages
Child abuse and mistreatment
16
Targeted data collection
• Parent/carer medical history or patient declaration (based on the age) • Presence of any underlying pathologies (coagulation disorders, imperfect osteogenesis etc.)
Child abuse and mistreatment
17
Triage code attribution
Always assign a priority code based on the patient’s clinical condition but not lower than a code «3»
Child abuse and mistreatment
18
Intra-hospital triage regional manual Lazio model with five codes PEDIATRIC TRIAGE OF ABUSE/MISTREATMENT TRIAGE CODE
1
2
3
4
5
Vital parameters
from code 1
from code 2
from code 3
from code 4
from code 5
Characteristics of the main symptom/sign
Massive hemorrhage in progress.Sexual abuse.
Reported ill-treatment At least 1 positive item in the absence of among the indicators obvious physical Not expected of risk of abuse in use. injuries.
Not expected
Associated symptoms/signs Specific scores
Pain
Pain
2
3
Counseling activation
Enable local protocol
Enable local protocol
Pain therapy
According to local protocol
Revaluation
Direct or videomediated observation with constant condition monitoring
TRIAGE PROCEDURES
1
4
5
Activities
Other
Repetition of part or all of the evaluation phases on the decision of the triagist, at the request of the patient, once the maximum recommended waiting time has elapsed
See sheets of any associated symptoms.
Child abuse and mistreatment
19
In conclusion
The nurse represents the first moment of contact and trust. The nurse must not formulate judgements, must not investigate what happened, must not force anything but only welcome and direct the patient towards the most appropriate clinical pathway. • • • • •
The child must be comfortable in a calm environment There must be no external disturbances (privacy) Only the strictly indispensable operators must be present If possible, a single visit should be made Always explain to the child what you are doing
Child abuse and mistreatment
20