Nursing Care of the

Maltreated Child

Objectives
Describe major categories of child abuse
Relay risk factors placing children at risk
for abuse
Describe long-term effects of abuse
Describe and interpret assessment findings
that increase suspicion for abuse
Identify appropriate nursing interventions
for the child subject to abuse.

 In 2011, there were 3.4 million reports of child abuse which

included an estimated 6.2 million children in the United States.

Each day 10,000+ children are abused, molested, or tortured & 5
of those children will die from the abuse.
93% of abused children are abused by someone they know and
trust.
The estimated cost of care related to child abuse in this country
alone is $124 billion dollars!

Impacts & Effects

Abuse and neglect in the United States has
increased 134% since 1980.
Abused children are 6x more likely to abuse their
children some day.
Abused children are 24x more likely to commit
sexual assault, 74x more likely to commit crimes
against others, 50x more likely to abuse alcohol or
drugs.
Abused children are 25% more likely to experience
teen pregnancy.

Quiz
1. What are two factors putting a child at
risk for abuse?
2. Which one of these is least suspicious for
Munchausen by proxy?
A. 3yo boy with complaints of repeated
vomiting episodes and poor weight gain that
resolves when hospitalized, mother has
personal Hx of pseudo-seizures.
B. 2yo child with ALTE (Apparent Life
Threatening Event) witnessed in day care and
church nursery, family has previous CPS report
of neglect.
C. 13 month old infant with frequent episodes

Quiz
3. What is a common physical assessment finding
in an infant with shaken baby syndrome?
A. Extensive bruising.
B. B. Fever.
C. C. Retinal bleeds seen with ophthalmoscope.
D. D. Elevated WBCs.

4. Children with frequent traumatic events such as

abuse, neglect or severe parental mental illness
are at higher risk for heart disease and lung
cancer later in life: T/F

Quiz
5. Which X-ray finding would trigger
further assessment for child abuse?
A. Distal right radius & metacarpal fracture
after a fall playing basketball.
B. Left clavicle fracture in an LGA (4.2kg)
newborn after vaginal delivery with shoulder
dystocia.
D. Spiral fracture of the femur in a 10 month
old child.

Acts of Commission &

Omission
Physical Neglect & Physical Abuse
Emotional Neglect & Emotional
Abuse
Sexual Abuse

What is Physical
Abuse?
The deliberate maltreatment of another individual
that inflicts pain or injury or may result in permanent
or temporary disfigurement or even death.
Most common types of child abuse:
Hitting, slapping, kicking, or punching
Whipping with belts, shoes, cords, etc.
Inflicting burns
Immersing child or body part in scalding water
Shaking
Tying the child to the bed or other object
Throwing the child against a wall, down the stairs etc.
Choking or gaging the child
Deliberately administering excessive doses of drugs

Risk
Factors
Age under 3 years
Parent was abused as a

child
Spousal abuse
Isolated from family or
friends
Chronic illness
Stress in families
Stepparents or paramour
in household
Drug or alcohol abuse
Social /economic group

Risk
Factors
History of mental illness,

domestic violence,
incarceration, or substance
abuse
Inadequate childcare or
supervision
Inadequate familial support
Access to firearms
High exposure to media
violence
If child has ADHD or other
developmental behavioral
issues
Use of corporal punishment
or other inappropriate
discipline methods

7 Deadly Sins of
Childhood:
1. Colic / incessant crying
2. Awakening at night
3. Separation anxiety
4. Normal exploratory behavior
5. Normal negativism
6. Poor appetite
7. Toilet training resistance or

accidents

Red
Flags
Injury is not
congruent with
description of
incident or
developmental
level of child
Stories not
consistent
Delay in seeking
care for a
significant injury

Clinical Manifestations
Multiple bruises in various stages of healing
Scald burns with clear lines of demarcation and in a glove or
stocking distribution
Rope, belt, or cord marks, usually seen on the mouth, butt,
back, legs, and arms
Burn scars in various stages of healing
Multiple fractures in various stages of healing
Spiral fractures not explained by accident
Shortness of breath and distress upon being moved
Cranial injuries
Abdominal injury

Other Suspicious
Findings

Human Bite
Marks

ng
Missi
Hair

Marks a
nd / or
Scratch
es

Other Suspicious
Findings: Burns

What If You See This?

What If You See This?

6 year old boy comes into the ER with right leg pain after
reportedly falling down. This is what the x-ray showed:

Is this abuse?

Review quiz questions

1. What are two factors putting a
child at risk for abuse?
5. Which X-ray finding would trigger
further assessment for child abuse: A.
Distal right radius & metacarpal fx after a
fall playing basketball. C. L clavicle
fracture in an LGA (4.2kg) newborn after
vaginal delivery with shoulder dystocia. D.
Spiral fracture of the femur in a 10 month
old child.

Shaken
Baby
Syndrome

Caused by shaking an
infant or child
10-12% of deaths from
abuse
1/3 survive with no
problems
1/3 suffer permanent
damage
1/3 die
Often crying is the
precipitating factor

http://www.youtube.com/watch?
v=THhFoYk7U40

Infant Anatomy
Underdeveloped bone
+
Underdeveloped
tissue
+
Underdeveloped neck
=
Increased risk for:
Brain Damage

Cerebral
Hemorrhages
Cerebral
Blood Clots
Retardation
Neck / Spinal Injury
Paralysis
Blindness & Deafness
Death

Shaken Baby
Syndrome

Clinical Manifestations
of SBS
Often no external signs
Subdural hemorrhage
Retinal hemorrhages
Apnea, seizures
Vomiting
Irritability
Poor suck / swallow / breathe (poor feeding)

Retinal Hemorrhages

Review quiz question

3. What is a common physical
assessment finding in an infant with
shaken baby syndrome?
A. Extensive bruising.
B. Fever.
C. Retinal bleeds seen with ophthalmoscope.

D. Elevated WBCs.

Sexual Abuse
The exploitation of a

child for the sexual gratification of

an adult.
A child is anyone who has not reached the age of consent,

EVEN IF A TEENAGER.
1 in 3 girls and 1 in 6 boys will be sexually abused by their

18th birthday.
The average age of children when they are sexually abused

is 4 years.
Most common abuser is the childs parent or guardian, a

male friend of the childs mother, or another family

members or friend.

Risk Factors in
Adults
Addiction, poor impulse control, low self
esteem, other personality disorders
Poor parenting experiences
Marital stressors
Environmental stressors
Social isolation
Inappropriate expectations for the
developmental level of the child

Sexual Abuse:
Clinical
Manifestations

Vaginal discharge

Fear of strangers

Blood-stained underpants
or diaper

Phobias about particular

places, people, or things

Genital redness, pain,

itching, or bruising

New or excessive sexual

curiosity or play

Difficulty walking or sitting

Sleeping problems

Constant masturbation
Curling into fetal position

Bed-wetting

Child or adolescent female

acts like a wife or mother

Unwillingness to be
around someone

Excessively seductive
behavior

UTI / STI

Child or adolescent works as

a prostitute

Sexual Abuse:
Clinical
Manifestations
Abrupt change in
school performance
Change in eating
habits
Abrupt changes in
behavior
(withdrawal)
Somatic complaints
(headache /
stomachaches)

These are frequently

about what for the
child?

http://www.youtube.com/watch?
v=AULaJdMPmIw

Emotional Abuse
Involves shaming, ridiculing,
embarrassing, or insulting the child.
May include destruction of property or
harming, killing, or giving away the childs
pet.
Intent of emotional abuse is to frighten or
control.
Witness to domestic violence

Clinical Manifestations
Change in behavior or school performance
Fear of avoidance of certain people, genders, or
situations
Anger and violent play
Sedation from overmedication
Exacerbation of chronic illness d/t
withholding of
medication
Inappropriate clothing for the season

Clinical
Manifestations
Poor physical growth
Failure to meet appropriate developmental
milestones and developmental delays
Child has difficulty relating to adults
Impaired communication skills
Behavioral signs: withdrawn, generalized
anxiety, fear, shame, aggression,
delinquency, depression; extreme efforts
to please

Munchausen by Proxy
Parent or caretaker fabricates the signs and

symptoms of disease
Causes the child unnecessary and potentially

harmful medical procedures, illness and

disability

Characteristics of
Mothers
Appear concerned and attentive / seldom leave
childs side
Offers to asset with care, including specimen
collection and meds
Trained in health related field
Intelligent and articulate
Absent father
Meets unmet needs for nurturing

Warning
Signs
Bizarre signs and

symptoms with no
apparent pathological
explanation
Symptoms recur or

persist despite active

management
Signs dont occur in

absence of mother
Never seen a case like

this before
Polymicrobial bacteremia
Seeks care at multiple

settings

Review quiz question

2. Which one of these is LEAST likely to be
Munchausen by proxy?
A. 3yo boy with a Hx of repeated vomiting episodes
and poor weight gain that resolves when hospitalized,
mother has personal Hx of pseudo-seizures.
B. 2 month old child with ALTE occurring in day care,
family has previous CPS report of neglect.
C. 13 month old infant with frequent episodes of
apnea. Mother reports that an older sibling died from
a similar condition about 3 years before.

Neglect
Most common type of child abuse but can be hard to
determine
Emotional neglect is characterized by the caretakers
emotional unavailability to the child.
Cold interactions that lack sensitive personal attention
What if the parent is mentally ill, or abusing illegal substances?

Physical neglect is the deliberate withholding of or failure to

provide the necessary and available resources to the child.
Supervision appropriate to the childs age
Adequate nutrition and hydration
Hygiene
Shelter
Appropriate healthcare (medical neglect?)

Child Abuse

Long Term
Effects

Based on what we have learned

today, what might some long term
effects of child abuse be?

Erickson

Maslow

Child abuse casts a

shadow the length of a
lifetime.
Children who have been abused are more
Herbert Ward

likely to abuse others in their future. This is

related to:
A long period of abuse
Use of violent force or threat of violence
Abuse involving penetration
Abuse involving family members, especially
the father or stepfather

Adverse Childhood
Experiences Study
Studied effects of Adverse Childhood Experiences
(ACE) on health outcomes in adults.
Included: physical, emotional, sexual abuse,
growing up with parental mental illness & drug
use, incarceration, parental divorce & domestic
violence.
Those with score of 4 or more, higher risk of
depression (4.5x), COPD (2.5x), suicide (12x).
Those with scores 7 and higher: 3.5x risk of CAD,
3x risk of lung CA.

Review quiz question

4. Children with frequent traumatic
events such as abuse, neglect or severe
parental mental illness are at higher risk
for heart disease and lung cancer as
adults: T/F

Nursing
Responsibilities
Detection
Documentation
Location, color, size, shape of any injury
Childs anxiety level and response to others
Statements made by child/parent

Reporting: Mandated by law to report suspected

abuse
Always try to remain:

NONJUDGEMENTAL &
SUPPORTIVE!

LISTEN, EDUCATE &

RAISE AWARENESS!

See if you can ID the

risk factors & red flags

Father as
passive o
Age
bserver
inadequat
e familial
r
e
h
t
o
M
support
Alcoholic
s:
n
g
i
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l
a
c
i
s
y
h
P
r
e
h
tabbed
t
S
o
M
Single
- Burn marks
Mothe
r abus
ed
in past

- Breathing
difficulty?
ped
- Under develo

Isolate
s
lm
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