ABUSE
| PEDIATRIC ABUSE —Gwendolyn Gladstone, MD, Adjunct Associate Professor of Pediatrics, Darthmouth Medical
School, Hanover, NH, and Clinical Instructor in Pediatrics, Harvard Medical School, Boston, MA
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| Case 1: Liam, 2 mo of age, comes in with father; infant fussy; on examination, leg sore; sent for x-ray of femur and found
to have spiral fracture; must determine why broken in such way; like any other medical problem, obtain history and perform
physical examination; may order laboratory testing or x-rays; ≈60% of infants <1 yr of age with fracture of femur
abused
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| Taking history of abused child: problematic if abusive caretaker accompanies child to emergency department (ED),
as he or she not likely to tell truth; raising topic of possible abuse will likely end positive relationship with caretaker, but
also true that caretaker who understands child’s interest main consideration more likely to cooperate; suggestions—ask
open-ended questions, eg, can you tell me what happened? try to engage parent or caretaker in diagnostic process; offer
alternative explanations, eg, medical condition that can cause easy fracturability, before suggesting abuse; be forthright
about possibility of abuse; some parents may misinterpret comment as personal affront, so important to make clear that
physician not personally accusing them, just looking for possibilities; may help to involve social worker in ED (explain to
parents that helpful to have someone with experience in field, eg, social worker, involved)
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| Physical examination: any injury in child should prompt careful head-to-toe examination to look for other trauma; retrospective
review of abused child’s medical chart likely will show frequent visits to ED, family practitioner, or pediatrician;
retinal hemorrhages—most specific for abuse (although not pathognomonic) multilayered hemorrhages and
hemorrhages that extend to periphery of retina (ora serrata); retinoschisis—even more specific for abuse; tearing away
of retina by attached vitreous; described in children only in cases of abuse and crushing head injury; strong indicator of
shaking injury; also examine anogenital region
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| Laboratory studies: fractures in children—rickets one of more common causes; calcium, phosphorus, and alkaline
phosphatase levels indicated; differential diagnosis can include genetic conditions, nutritional problems, infectious
causes, and osteogenesis imperfecta
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| Skeletal survey: demonstrates nonobvious fractures (no bruising, deformity, or pain); should be done in children <2 yr
of age with known physical abuse and for twin of abused child (association of abuse in twins extraordinarily high); series
of 20 specific high-resolution images; rib fractures—sometimes incidental finding on chest x-ray; easy to miss; bucket-
handle fracture—caused by severe traction on extremity; common in flailing that happens when child shaken violently
or jerked roughly by extremity
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| Further work-up: should include computed tomography (CT) of head, as occult intracranial bleeding hallmark of abuse
(easy to miss because symptoms absent or nonspecific); dilated retinal examination by ophthalmologist; social service
evaluation; Department of Children, Youth, and Families (DCYF) should be called for cases of long-bone fracture without
clear explanation in nonambulatory children; initial skeletal survey helpful immediately in acute fractures, but can
miss hairline fractures or subtle fractures; if index of suspicion high, either have child removed from suspected abuser
and repeat survey after 2 wk or perform bone scan; summary—fractures in young infants frequently caused by abuse;
establishing abuse requires careful history, physical examination, laboratory tests, x-ray evaluation, and social service
evaluation
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| Case 2: “Fussy Frances” checked into ED at 3 AM with frazzled mother who says baby won’t stop crying and vomits
when she tries to feed her; history reveals Frances born full-term, without problems; followed by primary care provider
who changed her formula twice due to colic; lives with both parents who work and attends day-care center; physical
examination—child afebrile, has age-appropriate growth parameters, runny nose, irritable but consoled by swaddling
and being walked up and down in dark room, and drinks 4 mL of oral electrolyte mixture (Pedialyte) without vomiting;
differential diagnosis—includes abusive head injury (shaken baby syndrome [SBS])
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| Abusive head injury: can be both cause and consequence of crying in infant; usually occurs without bruises, scalp
swelling, or other external signs of trauma; commonly misdiagnosed; study—173 children <3 yr of age diagnosed with
abusive head injury; almost one third seen by physicians after abuse, and diagnosis not recognized (especially true in
young white infants with intact families); 15 of abused children reinjured after missed diagnosis; 22 experienced medical
complication related to missed diagnosis; 4 of 5 deaths thought preventable had diagnosis been made in timely manner;
evaluation—skull films if positive history of impact or local swelling and bruising present; CT of head—most sensitive
method for detecting central nervous system (CNS) hemorrhage; usually done acutely; does not require sedation and takes
only few minutes; after several days, magnetic resonance imaging (MRI) better study but requires sedation; in telephone
survey, 2% to 3% of parents admitted to shaking or slapping their infants <1 yr of age to get them to stop crying; case fatality
rate ≈1 in 150; summary—can have subtle findings in infants; misdiagnosis common; must maintain high level of suspicion
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| Case 3: Samantha checks in at triage desk for rash in “privates”; rash diagnosed as routine skin problem; on examination,
hymen irregular and gapes open, with vaginal interior easily seen; question of sexual abuse
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| Sexual abuse: study by Makaroff et al—46 consecutive prepubertal girls seen at ED and diagnosed as sexually abused,
based on physical findings (looking at genitalia); all sent to child abuse expert; 8 had evidence of abuse, 32 had nonspecific
findings, 4 had normal findings, and 2 had findings more common in abused children but not diagnostic for abuse; if
unsure of diagnosis—obtain more careful history; helpful to talk to parent alone and child alone; choice of calling in
expert to ED; if necessary, refer for follow-up expert examination at later date; Child Abuse Referral and Evaluation
(CARE)—network of providers in state with commitment to objectivity and ongoing quality (peer review and continuing
education); providers willing to go to court and testify; improved remuneration from Medicaid; can evaluate children and
adolescents in acute and nonacute settings; providers organized by county; if specialty care needed but not available—
determine whether child needs immediate evaluation or can wait 1 or 2 days; first, determine whether patient medically
stable (no bleeding, pain, significant infection, or significant emotional distress on part of parent or patient); second, determine
safety of child; third, determine acuity; for sexually mature patient, “acute” event means sexual assault with vaginal
penetration that occurred within preceding 5 days; for sexually immature patient, “acute” means sexual assault within
past 24 hr for purposes of evidence collection; difference due to length of time in which possible to recover forensic evidence
from child’s body, as compared to adult’s body; forensic evidence disappears rapidly from child’s body; bed linens
common site of forensic evidence; acute sexual assault of child <13 yr of age warrants examination by CARE provider or
sexual assault nurse examiner with pediatric training; summary—involve expert immediately or refer for next-day appointment
if child medically stable, safe from further abuse, and last abusive act not acute
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| Reporting: child sexual abuse is a social service problem and a crime; person who suspects abuse responsible for reporting;
if responsibility delegated, make sure reporting done; report to DCYF and police in town where abuse took place
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| Physical findings in cases of penetrating sexual abuse: <5% of prepubertal girls seen nonacutely who describe
penetration of their genitals have physical findings indicating penetrating trauma; reasons for lack of physical examination
findings—hymen is elastic tissue, so penetration may stretch but not injure it; tissues can heal; several acts done in sexual
abuse (eg, touching, fondling) nontraumatic; “inside” does not always mean penetration through hymen; “inside” in legal terms
means penetration (however slight) of genitalia; for this reason, history given by child often more important than medical findings;
taking history from child—important medically and legally; “hearsay rule” does not apply to medical history; explain
your role to child; request accuracy; ask for questions or worries; keep questions and responses open-ended, eg, “what was that
like for you?”
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| ELDER ABUSE —Michael Klevens, MD, Adjunct Instructor of Emergency Medicine, Washington University School of
Medicine, St. Louis, MO, and Emergency Physician, St. Luke’s Hospital, Chesterfield, MO
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| Statistics: elderly defined as >65 yr of age; elder abuse—median age 78 yr; perpetrators mainly white people; two thirds
of perpetrators family members
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| Reporting: mandatory reporting in 46 states; penalties for failure to report; ED visit or other physician visit may be only
opportunity for intervention
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| Reasons for failure to detect elder abuse: busy schedule of physician not compatible with time necessary to conduct
separate in-depth interview with victim and family members; vague signs and symptoms; survey revealed only 25%
of emergency physicians recall education about elder abuse during residency; spectrum of family violence—ED physicians
better at recognizing and screening for child abuse and domestic or intimate partner violence than elder abuse; elder
abuse can occur in domestic or institutional settings, and also may involve self-neglect or self-abuse
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 | Physical: defined as intentional use of physical force; includes forced feeding, overmedicating, hitting, and use of weapons
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| Sexual: includes assault, coercion, verbal sexual abuse, physical sexual abuse (different from assault), and indecent exposure
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| Emotional or psychologic: eg, threatening to institutionalize, withholding food, medicine, or water
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| Financial or material exploitation: 14% of all abuse; somewhat limited by direct deposit of benefits from Medicaid,
Medicare, and Social Security
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| Abandonment: complete desertion by custodian or caregiver
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| Self-neglect: failure of elder person to provide for own mental and medical care; high correlation with depression and dementia
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| Neglect: not providing food, clothing, medicine, shelter, supervision or social support; intentional or unintentional; difficult
to prove, but most common form of elder mistreatment
|
| Risk factors: institutional—poor working conditions; inadequate training, experience, and supervision; low wages; low
staff-to-patient ratio; language barriers; environmental and family—shared living situations; overcrowded living conditions;
lack of family and community support; social isolation (creates barriers to health care); elder risk factors—cognitive
impairment or dementia (correlates directly with abuse); female sex; physical or functional impairment; financial dependence
of elder on caregiver or caregiver on elder; social isolation; history of family violence; aggressive or embarassing behavior
by elder; advanced age; incontinence; frequent falls; caregiver risk factors—financial stress (dependence on
elder); caregiver stress (feelings of being overwhelmed, frustrated, or resentful); alcohol or drug abuse; mental illness; lack
of skills or training (often, least capable family member thrust into caregiving role)
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| Language barriers: work with professional interpreter; do not depend on children, relatives, or friends to interpret;
speak directly with patient as much as possible
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| Red flags: medication uncertainties and lack of compliance; abandonment in ED; delay between injury or illness and ED
visit; elder especially at risk during acute decline (functional disability; decrease in cognitive ability)
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| Medical history indicators: talking with Emergency Medical Services (EMS) personnel about appearance of patient’s
living space may give clues about abuse; determine whether—patient fearful of companion; caretaker indifferent to or
angry at patient, overly concerned about costs, or reluctant to have physician interact privately with patient
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| How to speak with elderly patient: position yourself in front of patient; be seated if possible; speak slowly and
clearly and not in medical terms; favor monosyllabic words; low tone of voice; well-lit room to facilitate lip reading; discharge
literature should have large print; ask about relationships; ask direct questions (who cooks your meals? who takes
care of you?)
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| Speaking with caregiver: avoid confrontation (be nonthreatening and nonjudgmental); have separate conversation with
patient; ask specifically why patient in ED; discussion techniques—validate, empathize, generalize, and empower
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| Physical examination: check skin, back, buttocks, and bilateral arms; look for rib fractures and decubiti; check oral
area; check whether clothing appropriate for current weather; observe gait; diagnostic testing—of minimum value, except
for basic metabolic panel and drug and alcohol levels for toxicity; documentation—photographs; descriptions or
detailed drawings of injuries
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| Capacity: individual must understand options, consequences of acting on options, and risks and benefits of those consequences;
must admit elder to hospital if incapacitated; need geriatric psychiatric evaluation to determine whether patient
able to continue on own
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| Victim denial: embarrassment; intimidation; feeling overwhelmed; fear of outcome of reporting (being removed from
home and placed in nursing home); patients often ignorant about home health services
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| Difficulty in validating screening tools: no biomarker or reliable screening tool for elder abuse; 5-item checklist
(SAVED)—stress or social isolation; alcohol or drug use; violence; emotions (psychiatric disease); dependence (drugs)/
dynamics in family
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| Disposition: admit or discharge; can discharge if elder reliable or has reliable caregiver; problem if obvious self-neglect
or abuse present and elder has capacity; if not incapacitated, must respect wishes of elder; educate victim and give information
in writing; assure close follow-up; make appointment for follow-up next day or call house during next shift
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| Community programs: Meals on Wheels; visiting nurses or home health aides
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Educational Objectives
| The goal of this program is to educate the listener about child and elder abuse. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Recognize and diagnose abuse in a child.
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| 2. Determine when to use the skeletal survey and other work-ups for child abuse
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| 3. Examine a child for sexual abuse.
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| 4. Recognize and diagnose elder abuse.
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| 5. Identify the risk factors for elder abuse.
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To locate lectures of related interest, or to see a complete listing of Audio-Digest CME Programs, including written summaries.
Suggested Reading
Burgess AW et al: Children's adjustment 15 years after daycare abuse. J Forensic Nurs 1:73, 2005; Burgess AW et
al: Information processing of sexual abuse in elders. J Forensic Nurs 2:113, 2006; Campbell KA et al: The other children:
a survey of child abuse physicians on the medical evaluation of children living with a physically abused child. Arch
Pediatr Adolesc Med 160:1241, 2006; Cicchetti D et al: Fostering secure attachment in infants in maltreating families
through preventive interventions. Dev Psychopathol 18:623, 2006; Collins KA: Elder maltreatment: a review. Arch
Pathol Lab Med 130:1290, 2006; Daly JM et al: Readability and content of elder abuse instruments. J Elder Abuse
Negl 17:31, 2005; Dozier M et al: The role of early stressors in child health and mental health outcomes. Arch Pediatr
Adolesc Med 160:1300, 2006; Flaherty EG et al: Effect of early childhood adversity on child health. Arch Pediatr Adolesc
Med 160:1232, 2006; Ghetti S et al: What can subjective forgetting tell us about memory for childhood trauma?
Mem Cognit 34:1011, 2006; Gunnar MR et al: Bringing basic research on early experience and stress neurobiology to
bear on preventive interventions for neglected and maltreated children. Dev Psychopathol 18:651, 2006; Harkness KL
et al: The role of childhood abuse and neglect in the sensitization to stressful life events in adolescent depression. J Abnorm
Psychol 115:730, 2006; Heim C et al: Early adverse experience and risk for chronic fatigue syndrome: results
from a population-based study. Arch Gen Psychiatry 63:1258, 2006; Howe ML et al: Children's basic memory processes,
stress, and maltreatment. Dev Psychopathol 18:759, 2006; Jones H et al: Old age, vulnerability and sexual violence:
implications for knowledge and practice. Int Nurs Rev 53:211, 2006; Kemp B et al: Elder financial abuse: Tips
for the medical director. J Am Med Dir Assoc 7:591, 2006; Epub 2006 Oct 4. Littell JH et al: Correlates of problem
recognition and intentions to change among caregivers of abused and neglected children. Child Abuse Negl 30:1381, 2006;
Epub 2006 Nov 20. Mapp SC: The effects of sexual abuse as a child on the risk of mothers physically abusing their children:
a path analysis using systems theory. Child Abuse Negl 30:1293, 2006; Epub 2006 Nov 16. Morgenbesser LI et
al: Media surveillance of elder sexual abuse cases. J Forensic Nurs 2:121, 2006; Muehlbauer M et al: Elder abuse
and neglect. J Psychosoc Nurs Ment Health Serv 44:43, 2006; Pearsall C: Forensic biomarkers of elder abuse: what clinicians
need to know. J Forensic Nurs 1:182, 2005; Robarts J: Music therapy with sexually abused children. Clin Child
Psychol Psychiatry 11:249, 2006; Rodriguez MA et al: Mandatory reporting of elder abuse: between a rock and a hard
place. Ann Fam Med 4:403, 2006; Savell S: Child sexual abuse: are health care providers looking the other way? J Forensic
Nurs 1:78, 2005; Schofield RB: Office of Justice Programs focuses on studying and preventing elder abuse. J Forensic
Nurs 2:150, 2006; Shellem P: The killer next door: an analysis of investigative journalism. J Forensic Nurs
2:134, 2006; Singh R et al: Power and parenting assessments: the intersecting levels of culture, race, class and gender.
Clin Child Psychol Psychiatry 11:9, 2006; Theodore AD et al: A survey of pediatricians' attitudes and experiences
with court in cases of child maltreatment. Child Abuse Negl 30:1353, 2006; Epub 2006 Nov 13. Unternahrer I et al:
Gender and the relationship between traumatic childhood experiences and pain in adulthood. Swiss Med Wkly 136:637,
2006; Wang JJ et al: Psychologically abusive behavior by those caring for the elderly in a domestic context. Geriatr
Nurs 27:284, 2006; Welbury R: Child protection. Eur Arch Paediatr Dent 7:122, 2006; Widom CS et al: A prospective
investigation of major depressive disorder and comorbidity in abused and neglected children grown up. Arch Gen
Psychiatry 64:49, 2007; Widom CS et al: An examination of pathways from childhood victimization to violence: the
role of early aggression and problematic alcohol use. Violence Vict 21:675, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Gladstone was recorded May 15, 2006, in Lebanon, NH, at Managing Medical Emergencies, sponsored by the Dartmouth-Hitchcock
Medical Center and the New Hampshire Chapter of the American College of Emergency Physicians. Dr.
Klevens was recorded February 16-18, 2006, in San Antonio, TX, at the 12th Annual Scientific Assembly, of the American
Academy of Emergency Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
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