Child Abuse and Pediatric Head Trauma

Contact Hours: 2

This online independent study activity is credited for 2 contact hours at completion.

Course Purpose

To provide healthcare providers with an overview of child abuse and pediatric abusive head trauma.

Overview

Child abuse and neglect are serious public health concerns. It involves the emotional, sexual, physical abuse, or neglect of a child under the age of 18 by a parent, custodian, or caregiver that results in potential harm, harm, or a threat of harm. Physical abuse can result in pediatric head trauma; namely shaken baby syndrome, which in severe cases, has a 20 % mortality rate. Victims of child abuse are often brought to healthcare facilities for treatment, however often, the ailments of the child are not identified as potential child abuse. This independent study provides an overview of child abuse and pediatric abusive head trauma.

Objectives:

By the end of this learning activity, the learner will be able to: • Identify the risk factors, signs, and symptoms of child abuse • Define pediatric head trauma • Describe common diagnostic tools and exams as they relate to child abuse and pediatric head trauma • Describe the legal reporting requirements of child abuse

Policy Statement

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Disclosures

Fast CE For Less, Inc. and its authors no disclosures. There is no commercial support.

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Family and Domestic violence are a common problem in the United States and affects approximately 10 million people every year. They are abusive behaviors in which one individual gains power over another individual. Domestic and family violence occurs in all ages, races, and sexes. It knows no cultural, educational, geographic, religious, socioeconomic limitations. Domestic and family violence includes child abuse, intimate partner abuse, and elder abuse and encompasses economic, physical, sexual, emotional, and psychological abuse toward children, adults, and elders.⁴˒⁵ It causes diminished psychological and physical health and decreases the quality of life.

Child abuse and neglect are serious public health concerns. Child abuse includes all four types of abuse and neglect against a child under the age of 18 by a parent, caregiver, or another person in a custodial role that results in harm, potential for harm, or threat of harm to a child. The four common types of abuse and neglect include emotional abuse, physical abuse, sexual abuse, and neglect.

Domestic and family violence, including child abuse often starts when a caretaker or parent feels the need to dominate or control a child. This can occur because of several reasons, such as:

• Alcohol and drugs use, as an impaired individual may be less likely to control violent impulses
• Anger management issues
• Learned behavior from growing up in a family where domestic violence was accepted
• Personality disorder or psychological disorder

While the research is not definitive, several characteristics are thought to be present in perpetrators of child abuse. Abusers tend to:

• Be nonbiological, transient caregivers in the home, such as a parent’s significant other
• Have a history of substance abuse and/or mental health issues including depression in the family
• Have a parental history of child abuse and or neglect
• Have parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
• Have thoughts and emotions that tend to support or justify maltreatment behaviors
• Lack understanding of children’s needs, child development and parenting skills

There are several risk factors for child abuse, which are inclusive of individual, family, and community issues. For instance, there is a correlating relationship between parental stress and child abuse. The more stress a parent experiences, such as with separation or divorce, the more likely they will be involved in child abuse.

Exposure to domestic abuse and family violence as a child is commonly associated with becoming a perpetrator of domestic violence as an adult. This cycle occurs because children who are victims or witness domestic and family violence may believe that violence is a reasonable way to resolve a conflict. As a child grows to become an adult, they may solve conflicts in a manner that is familiar to them, often resulting in a repeated cycle of domestic violence. Males who learn that females are not equally respected are more likely to abuse females in adulthood. Females who witness domestic violence as children are more likely to be victimized by their spouses. While females are often the victim of domestic violence, the gender roles can be reversed. Perpetrators of domestic violence commonly repeat acts of violence with new partners, and drug and alcohol abuse greatly increase these risks. ¹⁴ Common risk factors for domestic violence include:

• A family history of violence
• Aggressive behavior as a youth
• Antisocial personality disorder
• Corporal punishment in the household
• Domination, which may include emotional, physical, or sexual abuse that may be caused by an interaction of situational and individual factors. This means the abuser learns violent behavior from their family, community, or culture. They see violence and are victims of violence.
• Economic stress in families with low annual incomes
• Females whose educational or occupational level is higher than their spouse’s
• History of abuse as children
• Individuals with disabilities
• Low education
• Low self-esteem
• Marital discord
• Marital infidelity
• Multiple children
• Poor legal sanctions or enforcement of laws
• Poor parenting
• Pregnancy
• Psychiatric history
• The use and abuse of alcohol and drugs is strongly associated with a high probability of violence. Alcohol abuse is known to be a strong predictor of acute injury.
• Unemployment

Abuse usually begins with emotional or verbal threats and may escalate to physical violence. Victims of child abuse live in a constant state of fear. Often, the abuser can become explosively violent. After the violent event, the abuser may apologize. This cycle usually repeats in child abuse. ¹¹˒¹²˒¹³ No matter the underlying circumstances, nothing justifies child abuse. Understanding the causes assists in understanding the behavior of an abuser. The abuser must be separated from the potential victim and treated for destructive behavior before a major event negatively impacts the lives of all involved.

At least 14% of children have experienced child abuse and/or neglect in the past year, and due to barriers/lack of reporting, this is likely an underestimate. Rates of child abuse and neglect are 5 times higher for children in families with low socio-economic status compared to children in families with higher socio-economic status. In 2018, nearly 1,770 children died of abuse and neglect in the United States. The total lifetime economic burden associated with child abuse and neglect is approximately $428 billion. This economic burden is like the costs of other public health problems, such as type 2 diabetes and stroke.

Each year, pediatric head trauma results in over 500,000 emergency department visits and about 60,000 hospitalizations in the United States. ¹ Fatal head trauma in children is mainly caused by abuse. Falls and sports/recreation-related head injuries rarely cause fatal injuries but can cause post-concussive symptoms in up to 30% of children. Falls are more common in children 0 to 4-years of age, while sports and recreation-related injuries are more common in children 5 to 14 years of age.

Federal Child Abuse Prevention and Treatment Act (CAPTA):

Each state has specific child abuse statues. Federal legislation provides guidelines for defining acts that constitute child abuse. The guidelines suggest that child abuse includes an act or failure to act that presents an imminent risk of serious harm. This includes any recent act or failure to act on the part of a parent or caretaker that results in death, physical or emotional harm, sexual abuse, or exploitation.

Victims of alleged child abuse or neglect have specialized needs during the assessment process. The Joint Commission requires hospitals to have policies for the identification, evaluation, management, and referral of victims. This includes:

• Safeguarding information and potential evidence that may be used in future actions as part of the legal process.
• Having policies and procedures that define responsibility for collecting these materials.
• Having policies that define activities and specify who is responsible for their implementation.
• Provide an opportunity for victims of domestic violence to obtain help.

Identifying a child of suspected abuse is difficult because the child may be nonverbal or too frightened or severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Healthcare providers will see children of abuse in a range of ways that include:

• An adult or mandated reporter may bring the child in when they are concerned about abuse
• A child or adolescent may come in disclosing the abuse
• The perpetrators may be concerned that the abuse is severe and bring in the patient for medical care
• The child may present for care unrelated to the abuse, and the abuse may be found incidentally

Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include interviewing the verbal child and each caretaker separately. The verbal child and parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the healthcare provider’s questions or interpretations.

Another outcome commonly associated with child sexual abuse is an increased risk of re-victimization throughout a person’s life. If a child demonstrates behavior such as undressing in front of others, touching others’ genitals, as well as trying to look at others underdressing, there may be a concern for sexual abuse. It is important to understand that a normal physical examination does not rule out sexual abuse. In fact, most sexual abuse victims have a normal anogenital examination. In most cases, the strongest evidence that sexual abuse has occurred is the child’s statement.

Children who are abused may be unkempt and/or malnourished, and may also display inappropriate behavior such as aggression, being withdrawn, and have poor communication skills. Others may be disruptive or hyperactive. They also may have poor school attendance.

Specific injuries and associated findings of child abuse include:

When considering child abuse, one must also identify differential diagnoses’ that may coincide with injuries. The diagnosis and injury type can vary with the child’s age. Various differential diagnosis’ and causes include:

When feasible, and without delaying care to the child, photographs of injuries should be taken prior to initiating treatment of suspected injuries of child abuse. • Take an identification tag photo. • Take photos from multiple injury angles and distances. • Measure and document injury sizes. • When photographing bite marks include photos focusing on each dental arch to avoid distortion. • Check photos as they may be used in court.

The initial assessment should proceed in a stepwise fashion to identify all injuries, as well as optimize cerebral perfusion by maintaining hemodynamic stabilization and oxygenation in children with severe head trauma. The initial survey should also include a brief, focused neurological examination with attention to the Glasgow Coma Scale (GCS), pupillary examination, and motor function.

The pediatric GCS is like the adult GCS, but the main difference is in the verbal response assessment. It has also been modified to address age appropriate responses within the pediatric population. For instance the pediatric GCS assigns a normal verbal score of 5 for babbling, cooing, or being oriented and using phrases appropriately, while subtracting 1 point if crying but consolable, using inappropriate words, or confusion, subtracting 2 points for inconsolable crying and incomprehensible words, subtracting 3 points for grunting or incomprehensible sounds, and subtracting 4 points for no verbal response.

After addressing any airway or circulatory deficits, a thorough head-to-toe physical examination must be performed with vigilance for occult injuries and careful attention to detect any of the following warning signs for head trauma:

Laboratory studies are often important for forensic evaluation and criminal prosecution. On occasion, certain diseases may mimic findings that are like child abuse, and therefore, they must be ruled out.

The evaluation of the pediatric skeleton can prove challenging for a non-specialist as there are subtle differences from adults and children, such as cranial sutures and incomplete bone growth. As a result, a fracture can be misinterpreted. When child abuse is suspected, a radiologist should be consulted to review the imaging results.

Initial management of an abused child involves stabilization, including assessing the child’s airway, breathing, and circulation. Airway adjuncts should be used in a child who is not able to maintain an open airway or maintain an oxygen saturation greater than 90% with supplementary oxygen. Oxygenation parameters should be monitored using continuous pulse oximetry with a target of greater than 90% oxygen saturation. Ventilation should be monitored with continuous capnography with an end-tidal CO2 target of 35 to 40 mm Hg. Placement of a definitive airway is recommended in the child with a Glasgow coma scale of less than 9.

The blood pressure should also be monitored, as systemic hypotension has been shown to negatively impact the outcome in a child with a traumatic brain injury. Maintaining a systolic blood pressure of 120 mm Hg has shown to demonstrate improved outcomes in children with brain injuries. If hypotension requires correction, isotonic crystalloids should be administered. Colloidal solutions have not been shown to improve outcomes of brain injury.

The child with a brain injury should also receive serial neurological examinations to identify early onset of elevated intracranial pressure (ICP) and implement subsequent interventions to improve intracranial pressure and reduce metabolic demands. Intervention to reduce intracranial pressure is imperative because the rate of mortality related to brain injury is caused by the elevated intracranial pressure.

Initial bedside interventions to reduce intracranial pressure include:

• Elevate the head of the bed to 30 degrees.
• Determine that the cervical collar (if in place) is not impeding venous outflow.
• Ensure that appropriate analgesics and sedation are administered because pain and anxiousness can increase the intracranial pressure. Opiates and benzodiazepines are frequently used, and neuromuscular blockade may be required to prevent actions that can increase ICP such as coughing, straining, and breathing against the ventilator.
• Hypertonic saline (3%) or mannitol are the common hyperosmolar agents that are used to reduce intracranial pressure.
• Routine hyperventilation in brain injury is not recommended, but in the setting of impending herniation, it remains one of the fastest, short-term methods to lower intracranial pressure.
• Intracranial pressure monitoring may be considered in infants and children with severe brain injury.
• Children with elevated ICP that is unresponsive to other therapies may benefit from barbiturates. These drugs are thought to decrease intracranial pressure by decreasing the cerebral metabolic rate.
• Decompressive hemicraniectomy is a surgical procedure that evacuates a hematoma, but it also is a primary treatment of resistant ICP. Increased intracranial pressure is reduced when part of the skull is removed through a decompressive hemicraniectomy.
• Hypothermia has not been shown to improve outcomes in children.

Once the healthcare provider ensures that the child is stable, a complete history and physical examination is required. Child protective services must be informed of any suspicion of child abuse. Having a child abuse specialist involved during the exam is optimal. If the child is seen in an outpatient setting, there may be a need to transfer the child to a hospital for laboratory and diagnostic testing as well as the appropriate continuation of care. Even if a child is transferred to another healthcare provider or facility, the initial healthcare provider first involved with the child’s care has the responsibility of being a mandated reporter. It is not the responsibility of the healthcare provider to identify the perpetrator, but it is their responsibility to recognize potential abuse. The healthcare provider must continue to advocate for the child by ensuring that they receive the appropriate follow-up care and services.

Likewise, victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed as well as empiric treatment for human immunodeficiency virus (HIV), gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection. This management is possible if the child presents to a healthcare provider within 72 hours of the abuse to receive appropriate care as well as emergency contraception if desired. Prepubertal children are not provided with the prophylactic treatment due to the low incidence of sexually transmitted infections in this age group. Urgent evaluation is beneficial in children for forensic evidence, who have anogenital injury, who need prophylactic treatment, need child protection, and in those having suicidal ideation or any other form of symptom and/or injury requiring urgent medical care.

Child abuse is a public health problem that leads to lifelong health consequences, both physically and psychologically. Physically, children who are victims of abusive head trauma may have neurologic deficits, developmental delays, cerebral palsy, and other forms of disability. Psychologically, victims of child abuse tend to have higher rates of depression, conduct disorder, and substance abuse. Academically, these children may have poor performance at school with decreased cognitive function. It is important for healthcare providers to have a high index of suspicion for child abuse because early identification may be lifesaving. All healthcare providers should report child abuse without hesitation.

When it comes to child abuse, all healthcare providers have a legal, medical, and moral obligation to identify the suspected abuse and report it to child protective services. Many child abuse victims present to health institutions, and healthcare providers are often the first ones to suspect abuse. The key is to be aware of signs of abuse. Allowing abused children to return to their perpetrators usually leads to more violence, and sometimes even death. Even if child abuse is only suspected, the healthcare provider must notify the appropriate personnel and agencies. The law favors the healthcare provider for reporting child abuse, even if it is only a suspicion. On the other hand, failing to report child abuse can have repercussions on the healthcare provider.

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