Abuse and Neglect

Article Author:
Oluwaseun Adigun
Article Author (Archived):
Ashraf Mikhail
Article Editor:
Jason Hatcher
Updated:
8/12/2019 7:28:18 PM
PubMed Link:
Abuse and Neglect

Introduction

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.[1][2]

Child abuse and neglect include:

  • Physical abuse
  • Sexual abuse or exploitation
  • Psychological abuse
  • Neglect or abandonment

Abuse and neglect of the elderly refer to physical, emotional, sexual abuse, or abandonment of the aged by relatives or caregivers.[3] Elderly abuse includes:

  • Physical abuse
  • Sexual abuse or exploitation
  • Financial exploitation
  • Emotional abuse
  • Confinement or neglect

Etiology

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.[4][5] Some of the identified risks are as follows:

  • Poor socioeconomic status: Poverty and unemployment among parents provide an unfortunate premise for abuse. Neglect may be as a result of a parent not able to provide basic needs for the child.
  • Domestic violence: Parents who abuse their partners have an increased tendency to abuse their children either directly or by indirect emotional trauma from the child constantly witnessing domestic violence.
  • Drug and alcohol abuse: Parents who abuse drug or alcohol are likely to be abusive.
  • Unwanted or unplanned pregnancy: Product of unwanted or unplanned pregnancy may suffer abuse or neglect either because the unprepared mother, who also may be a child, is not emotionally ready for the role.
  • Gender-based discrimination: In some societies, the female child is even more at risk. They suffer gender-based violence like female genital mutilation, early child marriage, and denial of education.

Elderly Abuse and Neglect

The following factors predispose the elderly to abuse and neglect:

  • Caregiver burnout: Care of the elderly can be burdensome.
  • Chronic health challenges: Elderly patients are over-dependent, and the caregiver may not be prepared to provide the needed support.
  • The onset of mental and behavioral challenges: The onset of memory loss in diseases like dementia and Alzheimer disease make the elderly prone to abuse and neglect.

Epidemiology

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.[6]

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.[7]

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).[8]

History and Physical

Child Abuse and Neglect

History

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:

  • Non-accidental injuries: children are brought into the emergency room with complaints of injury sustained while playing at home or even school, but the mechanism of injury often will not correspond with an injury sustained. Also, suggestive of abuse is an unexplained delay before presenting at the emergency room. Injuries may also reflect a lack of supervision by caregivers. Injuries may be in the form of bruises, abrasions, lacerations, fractures, burns, scald, or bites.
  • Other less common non-accidental injuries include intracranial injury (shaken baby syndrome may be a cause), stab injury, intra-abdominal injury from blunt trauma.

Physical Examination

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.[9][10]

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.[11]

Adult Abuse and Neglect

History

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.

Physical Examination

  • Unexplained signs of injury: Bruises, burns, scald, fracture, signs of restraints on the hands and feet
  • Bedsores, poor hygiene, unexplainable weight loss
  • Emotionally withdrawn and showing signs of depression
  • Refusal to take routine medications or drug overdose

Evaluation

Radiographs

X-rays are useful diagnostic tools for child abuse and neglect. Some suggestive features are as follows[12]:

  • X-rays showing multiple fractures with different stages of healing
  • Common sites of fracture are metaphyseal, scapular, sternal, and rib fractures

Treatment / Management

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.[13][14]

Management of abuse and neglect involves:

  • Treating presenting injuries and complaints
  • Reporting to appropriate authorities
  • Involving services of psychiatrists and psychologists
  • Discharge to child or adult protective services
  • Long-term follow-up and rehabilitation

Pearls and Other Issues

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.

Enhancing Healthcare Team Outcomes

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.[15][16]

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.[17][18]

Child advocacy centers recommend an interprofessional 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. [19]

Outcomes

Despite better awareness of the problem of child abuse, healthcare workers still miss many cases of abuse and neglect.[20][21] 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]


References

[1] Merrick MT,Guinn AS, Child Abuse and Neglect: Breaking the Intergenerational Link. American journal of public health. 2018 Sep     [PubMed PMID: 30088995]
[2] Mullen S,Quinn-Scoggins HD,Nuttall D,Kemp AM, Qualitative analysis of clinician experience in utilising the BuRN Tool (Burns Risk assessment for Neglect or abuse Tool) in clinical practice. Burns : journal of the International Society for Burn Injuries. 2018 Jul 31     [PubMed PMID: 30075971]
[3] Carey C,Hodges J,Webb JK, Changes in state legislation and the impacts on elder financial fraud and exploitation. Journal of elder abuse     [PubMed PMID: 30024309]
[4] Sattler KMP,Font SA,Gershoff ET, Age-specific risk factors associated with placement instability among foster children. Child abuse     [PubMed PMID: 30099229]
[5] Chandraratne NK,Fernando AD,Gunawardena N, Cultural adaptation, translation and validation of the ISPCAN Child Abuse Screening Tool - Retrospective Version (ICAST-R) for young adults in Sri Lanka. Child abuse     [PubMed PMID: 30036689]
[6] Devries K,Knight L,Petzold M,Merrill KG,Maxwell L,Williams A,Cappa C,Chan KL,Garcia-Moreno C,Hollis N,Kress H,Peterman A,Walsh SD,Kishor S,Guedes A,Bott S,Butron Riveros BC,Watts C,Abrahams N, Who perpetrates violence against children? A systematic analysis of age-specific and sex-specific data. BMJ paediatrics open. 2018     [PubMed PMID: 29637183]
[7] Devakumar D,Osrin D, Child Homicide: A Global Public Health Concern. PLoS medicine. 2016 Apr;     [PubMed PMID: 27115911]
[8] Rosen T,Stern ME,Mulcare MR,Elman A,McCarthy TJ,LoFaso VM,Bloemen EM,Clark S,Sharma R,Breckman R,Lachs MS, Emergency department provider perspectives on elder abuse and development of a novel ED-based multidisciplinary intervention team. Emergency medicine journal : EMJ. 2018 Aug 9     [PubMed PMID: 30093378]
[9] Karatekin C,Almy B,Mason SM,Borowsky I,Barnes A, Mental and Physical Health Profiles of Maltreated Youth. Child abuse     [PubMed PMID: 30036690]
[10] Christian CW,Levin AV, The Eye Examination in the Evaluation of Child Abuse. Pediatrics. 2018 Aug     [PubMed PMID: 30037976]
[11] Menke A,Lehrieder D,Fietz J,Leistner C,Wurst C,Stonawski S,Reitz J,Lechner K,Busch Y,Weber H,Deckert J,Domschke K, Childhood trauma dependent anxious depression sensitizes HPA axis function. Psychoneuroendocrinology. 2018 Jul 26     [PubMed PMID: 30086534]
[12] Cannell JJ,Holick MF, Multiple unexplained fractures in infants and child physical abuse. The Journal of steroid biochemistry and molecular biology. 2018 Jan     [PubMed PMID: 27641737]
[13] Ringel JS,Schultz D,Mendelsohn J,Holliday SB,Sieck K,Edochie I,Davis L, Improving Child Welfare Outcomes: Balancing Investments in Prevention and Treatment. Rand health quarterly. 2018 Mar     [PubMed PMID: 30083416]
[14] Rosen T,Stern ME,Elman A,Mulcare MR, Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department. Clinics in geriatric medicine. 2018 Aug     [PubMed PMID: 30031426]
[15] Ventura F,Caputo F,Molinelli A, Medico-legal aspects of deaths related to neglect and abandonment in the elderly. Aging clinical and experimental research. 2018 Feb 14     [PubMed PMID: 29442235]
[16] Krugman RD,Bross DC, Medicolegal aspects of child abuse and neglect. Neurosurgery clinics of North America. 2002 Apr     [PubMed PMID: 12391708]
[17] Ridout KK,Khan M,Ridout SJ, Adverse Childhood Experiences Run Deep: Toxic Early Life Stress, Telomeres, and Mitochondrial DNA Copy Number, the Biological Markers of Cumulative Stress. BioEssays : news and reviews in molecular, cellular and developmental biology. 2018 Aug 1     [PubMed PMID: 30067291]
[18] Carr A,Duff H,Craddock F, A Systematic Review of Reviews of the Outcome of Severe Neglect in Underresourced Childcare Institutions. Trauma, violence     [PubMed PMID: 29779452]
[19] Teeuw AH,Kraan RBJ,van Rijn RR,Bossuyt PMM,Heymans HSA, Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases. Acta paediatrica (Oslo, Norway : 1992). 2018 Jul 10     [PubMed PMID: 29992712]
[20] Sampson M,Read J, Are mental health staff getting better at asking about abuse and neglect? International journal of mental health nursing. 2017 Feb     [PubMed PMID: 27600259]
[21] Darlington Y,Feeney JA,Rixon K, Interagency collaboration between child protection and mental health services: practices, attitudes and barriers. Child abuse     [PubMed PMID: 16315352]