Abuse and neglect often affect children and the elderly.
Child abuse and neglect refer to the actions or inactions of a child's caregiver or parent who are capable of inflicting physical, sexual, or emotional harm on the child. It can also be referred to as child maltreatment and also has a definition within the legal framework of a country or state as constituting a criminal infringement of the rights of a child.
Child abuse and neglect include:
Abuse and neglect of the elderly refer to physical, emotional, sexual abuse, or abandonment of the aged by relatives or caregivers. Elderly abuse includes:
Child Abuse and Neglect
Predisposing factors are multifactorial, ranging from socioeconomic stressors to harmful cultural practices all contributing to the various degree of vulnerability among the world child population. Some of the identified risks are as follows:
Elderly Abuse and Neglect
The following factors predispose the elderly to abuse and neglect:
Prevalence of child abuse and neglect varies widely. Available estimates suggest that as much as a quarter of world adult population may have experienced some form of abuse or neglect during childhood with a slightly higher incidence in female subjects.
These values may not truly represent the actual incidence due to under-reporting.
Children are also victims of war and violent crimes. The World Health Organization (WHO) in 2014 estimated about 41000 cases of child homicide occur yearly.
Abuse of the elderly is equally common, in the United States of America, one in 10 people older than the age of 60 may have experienced some form of abuse, amounting to about 5 million cases per year (National Center on Elder Abuse).
Child Abuse and Neglect
Abuse and neglect often go unreported as perpetrators are often responsible for making health decisions on behalf of the victim, and to help cover up the act, victims are not allowed to present promptly, and when they present, they give evasive responses hence history obtained may be misleading. The following, however, are some common presenting complaints due to abuse and neglect:
Physical abuse: Bruises in infants less than 6 months (infants not yet freely mobile) are highly suggestive of abuse; likewise, bruises situated away from bony prominences, bruises with a unique shape (like the shape of an object. Limping may be an indication of a fracture. Other sign includes unexplained hair loss, retinal hemorrhages, unexplained loss of a tooth, unexplained bruising on the abdomen, and as altered consciousness in head injury.
Sexual abuse: The following are telltale signs, difficulty in walking or sitting, torn clothes, or underwear. There may be genital bruising or bleeding, or genital discharge. There may also be behavioral or personality changes, inappropriate behavior especially of the sexual nature, for example, an unusual interest in genitals of other children or even adults.
Emotional abuse and neglect: Poor hygiene, signs of malnutrition (child may refuse meals), the child may appear withdrawn with inadequate social interaction, milestone delays, for example, speech and motor delays.
Adult Abuse and Neglect
History of deteriorating health conditions, memory loss, urinary or fecal incontinence, behavioral changes, frequent unexplained visits to the emergency room, and close relatives may notice unusual financial transactions by the elderly.
X-rays are useful diagnostic tools for child abuse and neglect. Some suggestive features are as follows:
A high index of suspicion is required to make a diagnosis of non-accidental injury or abuse and neglect. While promptly attending to physical injuries, it is important to note that abuse and neglect have more lingering emotional or psychological sequelae that require management. The care of abused and neglected individuals and therefore requires a multidisciplinary approach. In managing child abuse and neglect, the following specialists must work together: general practitioners, emergency room doctors, pediatricians, psychiatrists, child psychologists, social workers, law enforcement officers, and members of the child protective services. Elder abuse and neglect require the services of general practitioners, emergency room doctors, geriatric specialists, psychiatrists, social workers, law enforcement officers, and members of adult protective services.
Management of abuse and neglect involves:
Different countries have legislation and policies for abuse and neglect against children or the elderly. The healthcare provider is mandated by law to report non-accidental injuries and suspected cases of abuse and neglect. The failure to report abuse may qualify legally as a misdemeanor.
Child abuse and neglect is a major public health problem. Even though there is more awareness of this social problem among healthcare workers, the problem still exists. Every day, at least 700 children are removed from their homes because of abuse and neglect. For many, the scars of physical, sexual, and mental abuse linger throughout life. Countering child abuse and neglect is not only the responsibility of the physician but all healthcare workers. There are laws in every state which encourage all healthcare workers to report child abuse, without fear of any repercussions.
The diagnosis of child abuse is not simple and requires a high degree of suspicion on the part of healthcare workers who encounter the child and the family. Abused children not only present to the physician but may have encounters with nurses, pharmacists, therapists, lab technologists, and many other allied professionals and all these professionals have a legal and moral duty to report any suspicion of child abuse. Those who do not report child abuse can even incur legal penalties. When child abuse goes undetected, it carries enormous morbidity and mortality for the child. Abused children often have unhealthy development with emotional scars that remain for life.
Child advocacy centers recommend an interdisciplinary team approach for child abuse detection. In many circumstances, a child may remain silent in the presence of a clinician but may reveal the dark secrets of abuse to other professionals. Thus, nurses, pharmacists, and other allied healthcare professionals must be vigilant about child abuse. Many screening tools have been developed, which can help healthcare workers make the diagnosis of child neglect or abuse. When a nurse or other health professional determines abuse is a concern, they should report to the clinical team leader their findings. Only through teamwork will better outcomes be achieved. 
Despite better awareness of the problem of child abuse, healthcare workers still miss many cases of abuse and neglect. The key reason is that some healthcare workers falsely believe that it is physicians who are solely responsible for intervention, which is erroneous thinking. All healthcare workers should report any suspicious case of child abuse and can verify with other members of the healthcare team to corroborate their findings. If done in good faith, the law will always protect them. This discernment and interaction/communication is a key component of a properly functioning interprofessional team and can be lifesaving as much as any other therapeutic activity. [Level V]
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