Child at risk

18.2 Child at risk



Simon Young, Raymond Chin, Gervase Chaney




Essentials



1 Non-accidental injury occurs when an adult responsible for the care of the child either harms the child or fails to protect the child from harm.

2 A child may be at risk from physical abuse, sexual abuse, emotional abuse or neglect.

3 Medical and nursing practitioners are often mandated by law to report suspicions of non accidental injury.


Introduction


Non-accidental injury is increasingly recognized as a major public health and social welfare problem with important short term and long lasting effects for children and adolescents. As Australian and New Zealand Emergency Departments (ED) provide care for many hundreds of thousands of children and adolescents each year, departments and their staff play an important role in the detection of abuse and initiation of a medical and community response. This response is aimed primarily at treating the child, minimising psychological effects and ensuring their safety.


Children and adolescents are, by virtue of their developing intellectual, emotional and physical state, a vulnerable group. The environment within which they develop is influenced by many factors outside their control: the economic and social status of their family, the personality and values of family members and friends, and the extent of physical and intellectual stimulation that they receive may all have profound influence upon their development. The potential variability in these factors and the recognition that negative experiences often have serious short- and long-term implications for the child has lead to a general acknowledgment that children and adolescents need protection.


The United Nations Convention on the Rights of the Child recognizes that:



… for the full and harmonious development of his or her personality, [a child] should grow up in a family environment, in an atmosphere of happiness, love and understanding ….


The Convention continues, stating in Article 19 that governments shall:



… take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child ….


It is this philosophy that has driven the creation of the social and legal framework of child protection. Doctors, nurses and other healthcare workers who deal with children are an integral part of this system that acts to protect children and adolescents. Every health professional that has contact with children needs to be aware of the possibility of non-accidental injury, must be able to detect when it is occurring and know how to act in the best interests of the child once it is suspected.



Definition


The child at risk is not a medical diagnosis but rather a description of certain forms of behaviour displayed by adults responsible for the care of a child. The child is at risk when an adult responsible for the care of the child harms, threatens to harm or fails to protect the child from harm. Harm may be either physical (e.g. inflicting an injury, causing pain or poisoning), psychological (e.g. causing feelings of being unloved or worthless) or both.


A child may be at risk from:


• physical injury;

• sexual abuse;

• emotional abuse;

• neglect.

These are not exclusive and a child may be subjected to more than one type of abuse.



Physical injury


This is the commonest type of abuse that is reported to child protection agencies. Many thousands of children present to EDs around Australia each year with a wide range of physical injuries, the vast majority of which are caused accidentally. It is a difficult but essential task to identify children within this group who have been injured as a consequence of abuse. While medical and nursing staff must be alert for the possibility of any non-accidental injury, there are specific circumstances that may raise suspicion. These include:


• situations where there are direct allegations of violence directed against the child made by the child or any other person;

• the type and pattern of injury observed at the examination;

• an explanation being offered for an injury that does not fit the type or pattern of injury;

• delayed presentation for medical care with an injury that a reasonable person would have recognised as needing care sooner;

• multiple presentations, often to different healthcare providers, seeking medical attention.

Once the possibility of non-accidental injury has been raised the priorities of the treating doctor are:


To diagnose, treat and document the child’s injuries.

To interpret the pattern of injury or behaviour as to the possible causes.

To notify and involve the agency responsible for ensuring safety of the child.

To provide a written or verbal report and advice to that agency or the police.


Presentation


Physical abuse may present to the ED in many different ways. Most commonly it will present as a child with an obvious injury and a suggestive history but in some situations it will be more subtle, such as a younger child who presents not using a limb.


Children who present with a decreased conscious state with no obvious cause may have a head injury from a blow or a fall or may have been poisoned. If the child is very young, the decreased conscious state may be a result of being shaken.



History


It is necessary to collect as much information as possible on the events that led to the child sustaining the injuries. Specifically, enquire as to when, where and how the injury happened, who was present at the time and what happened after the injury. The child’s medical, developmental and social history, with specific information on past injuries, is important.


This history must be sought in an open and non-judgemental fashion, which encourages the participants to reveal all the important information. Unfortunately, the ED is often not the ideal place to conduct a lengthy and in-depth forensic interview with the parents or carers and it may be prudent to limit the information gathering to items that will enable specific issues to be addressed. The interview can always be completed by trained investigators at a later time.



Physical examination


Prior to commencing the examination the doctor must ensure that the parents and, where appropriate, the child are informed of the nature and extent of the examination and that valid consent has been given. In addition it is ideal to have spent some time with the child, to gain their confidence and thus increase the chances of keeping their co-operation during the examination.


Consent from the parent or legal guardian is necessary to conduct a physical examination, to perform investigations (including photographs) and to release clinical information in the form of a report to a third party. If consent is refused the protective agency or police must seek a court order. If there is an urgent medical problem that needs intervention and such intervention is clearly in the best interests of the child, then the examination and treatment should proceed and not be delayed by the lack of consent.


An adolescent may be able to give consent for their own examination as long as they are capable of understanding what the examination entails, what the results will be used for, and the implications that this may have for them.


A thorough physical examination of the child should be performed, with observation and palpation of skin, soft tissues, bones and joints, and giving specific attention to the eyes, ears and mouth. The examination should look for the following physical findings:



Bruising of the skin


Bruises are extremely common in children. In the absence of a documented bleeding tendency they are evidence of blunt trauma and may provide some information on the site, the implement or force of an impact. Accidental bruises are commonly found in children once they have learnt to crawl, occurring over bony prominences, usually on the front of the body and are directly related to a child’s increasing motor activity. Babies who are not yet crawling rarely have accidental bruising.


Bruises caused by abuse may occur anywhere on a child’s body. Specifically, look in places where accidental bruises are uncommon such as the mouth, behind the ears, on the inner aspect of the upper arm and around the buttocks. Observe the shape and pattern of bruises, looking for features that may suggest a blow from an open hand or a single or multiple blows from an implement. Look for a pattern within the bruise that may suggest contact with a specific surface.


Whilst it is important to describe the appearance and colour of the bruising, it is not possible to be accurate about the age of a bruise. If a bruise is yellowing in colour then it is likely to be more than 18 hours old.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Child at risk

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