Child abuse

Reference :
1. Nelson textbook of pediatrics
2. A study on child abuse in india 2007
Dr Ruturaj Deshmukh
DNB Resident
Choithram Hospital & Research Centre,
Indore
www.dnbpediatrics.com

“So long as little children
are
allowed to suffer, there is no
true love in this world”
Duncan

 “Any recent act or failure to act on the part of a parent
or caretaker, which results in death, serious physical or
emotional harm, sexual abuse or exploitation.” (nelson)
 “Child abuse constitutes all forms of physical and/or emotional ill
treatment resulting in actual or potential harm to the child’s health,
survival, development or dignity in the context of a relationship of
responsibility, trust or power”. (WHO)

-Abuse most common in children < 1 yr. old
-Girls more frequently abused at older age vs.
boys

 Every fifth child in the world lives in India
 Every third malnourished child in the world lives in India
 Every second Indian child is underweight
 Three out of four children in India are anaemic
 Decline in female/male ratio is maximum in 0-6 years: 914
females per 1000 males
 Birth registration is just 62% (RGI-2004)
 Retention rate at Primary level is 71.01% (Elementary Education
in India Progress towards UEE NUEPA Flash
 Statistics DISE 2005-2006)
 Girls' enrolment in schools at primary level is 47.79%
(Elementary Education in India Progress towards UEE
 NUEPA Flash Statistics DISE 2005-2006)
 1104 lakh child labour in the country (SRO 2000)

 physical abuse
 sexual abuse
 emotional abuse
 neglect

“Physical abuse is any non-accidental injury to a child
under the age of 18 by a parent or caretaker. ”
These includes- beatings, shaking, burns, human
bites, strangulation, or immersion in scalding water or
others,
Which may results in:
1. Bruises and welts 2. fractures
3. Scars 4. burns
5. Internal injuries or any other injuries.

(1) bruising in a preambulatory infant ,
(2) bruising of padded and less exposed areas
(buttocks, cheeks, under the chin, genitalia),
(3) patterned bruising or burns conforming to shape of
an object or ligatures around the wrists
(4) multiple bruises, especially if clearly of different
ages.
Before confirming it we must rule out:
(1) birthmarks and Mongolian spots
(2) blood dyscrasias or connective tissue disorders
(hemophilia,Ehlers- Danlos).
(3) Henoch-Schonlein purpura
(4) coagulopathy
(5) Cultural practices

Bruises

 characteristic pattern- “1 or 2 opposing arches with
multiple bruises.”
 child bites: < 8 yr primary teeth typically have a distance
of less than 2.5 cm between the canines.
 Animal bites: usually have narrower arches than human
bites and are often deep.
 Self-inflicted bites are on accessible areas, particularly the
hands.
 Adult bites: canine distance
>2.5 cm and has broader arch.
 Multiple bites by another child
suggest inadequate supervision
and neglect.

 When to suspect abuse:
◦ Multiple fractures in various stages of healing.
◦ classic metaphyseal lesions
◦ posterior rib fractures,
◦ fractures of the scapula, sternum, and spinous processes, especially in young
children.
 Non abused #:
◦ Clavicle, femoral, supracondylar humeral, and distal extremity fractures in
children older than 2 yr are most likely noninflicted unless they are multiple or
accompanied by other signs of abuse
Differential diagnosis includes conditions that increase
susceptibility to fractures, such as osteopenia and osteogenesis
imperfecta, metabolic and nutritional disorders (e.g., scurvy,
rickets), renal osteodystrophy, osteomyelitis, congenital
syphilis, and neoplasia

A, Metaphyseal fracture of the distal tibia in a 3 mo old
infant admitted to the hospital with severe head injury

 When to suspect as abuse:
◦ it shows clear delineation between the burned and healthy
skin
◦ has uniform depth.
◦ mainly sock or glove distribution
◦ absent Splash marks.
◦ Symmetrical burns (especially suggestive of abuse as
are burns of the buttocks and perineum).
◦ pattern Burn (hot objects such as curling
irons, radiators, steam irons, metal grids,hot knives, and
cigarettes.)

1. ‘‘battered child syndrome’’: serious physical
abuse
repeated and devastating injury to the skin, skeletal system or
nervous system causing multiple fractures of different ages,
head trauma and severe visceral trauma, with evidence of
repeated infliction.
2. “The shaken infant”: (mainly < 1yr of age)
Intracranial haemorrhages, retinal haemorrhages and chip
fractures of the child’s extremities result from very rapid
shaking of an infant

 Neglect refers to the failure of a parent to provide for the development
of the child – where the parent is in a position to do so – in one or more
of the following areas: health, education, emotional development,
nutrition, shelter and safe living conditions.
 When to suspect :
• Begs for or hoards food
• States frequent/continual absence of parent or guardian
• Frequently dirty or not bathed
• Has unattended physical problems
• Shows extreme dependence or detachment
• Frequently hungry or inappropriately dressed
• Engages in delinquent behavior, such as like stealing

CHILD SEXUAL ABUSE:
Child sexual abuse is the exploitation of a child or
adolescent for the sexual gratification of another
person.
IT INCLUDS:
Oral-genital stimulation
Sodomy Verbal stimulation
Exhibitionism Voyeurism
Fondlin Child prostitution
Child pornography Intercourse

 Difficulty walking or sitting
 Demonstrates unusual sexual knowledge/behavior above developmental level
 Shows extreme compliance or defiance
 Sudden reluctance to change near others (for activities such as gym)
 Reported nightmares or bedwetting
 Sudden change in appetite
 Suddenly avoids a certain adult(s)
 Experiences pain when urinating
 Signs of eating disorders

Indicators of Child Abuse (Discovered by Family
Doctor)
Type of Abuse Physical Indicators Behavioral Indicators
Physical Unexplained bruises, welts, burns,
fractures, or bald patches on scalp
Wary of adult contact, frightened of
parents or afraid to go home,
withdrawn or aggressive, moves
uncomfortably, wears inappropriate
clothing for weather
Sexual Difficulty walking or sitting; torn or
stained/blood underclothes; pain,
itching, bruises, swelling in genital
area; frequent urinary or yeast
infections
Advanced sexual knowledge,
promiscuity, sudden school
difficulties, self-imposed social
isolation, avoidance of physical
contact or closeness, depression
Emotional Speech or communicative disorder,
delayed physical development,
exacerbation of existing conditions,
substance abuse
Habit disorders, antisocial or
destructive behaviors, neurotic traits,
behavior extremes, developmental
delays
Neglect Consistent hunger, poor hygiene,
inappropriate dress, unattended
medical problems, underweight,
failure to thrive
Self-destructive behaviors, begging or
stealing food, constant fatigue,
assuming adult responsibilities or
concerns, frequently absent or tardy,
states no caretaker in home

Do
Immediately tell the child you believe
them.
Tell them they were right to tell you, and
were brave to do so.
• Acknowledge that it is difficult talk
about this
• Tell the child that they are not
responsible and did not deserve it
• Ensure that the child feels safe following
disclosure
DON’T
• Panic or show that you are shocked.
REMAIN CALM!
• Never give the impression that you
might blame the child. Don’t ask: “Why
did you let him?”, “what were you doing
there anyways?” or “why didn’t you tell
me before?”.
• Don’t promise that you won’t tell
anyone if the child asks you to keep it a
secret
• Don’t ask intrusive questions. Listen but
don’t push for more answers.

 Consultation with a physician expert in child maltreatment is recommended.
 A thorough history should be obtained from the parent(s) optimally via
separate interviews.
 children should be interviewed separately, in a developmentally appropriate
manner.
 A thorough physical examination is necessary.
 Careful documentation of the history and physical is essential.
• For abuse: What is the evidence for concluding abuse? Have other
diagnoses been ruled out? What is the likely mechanism of the injury? When
did the injury likely occur?
• For neglect: Do the circumstances indicate that the child's needs have not
been adequately met? Is there evidence of actual harm? Is there evidence of
potential harm and on what basis? What is the nature of the neglect? Is there a
pattern of neglect
• What is contributing to the maltreatment? Consider the factors listed
under the section on etiology.

 Treat any medical problems.
Help ensure the child's safety, often in conjunction with CPS; this is a priority.
 Avoid blaming. It is natural to feel anger or pain towards parents of maltreated
children, but they need support and deserve respect
 Know your national and state laws and/or local CPS policies on reporting child
maltreatment
 Address contributory factors, prioritizing those most important and amenable to
being remedied
 Establish specific objectives, with measurable outcomes. Similarly, advice should
be specific and limited to a few reasonable steps. A written contract can be very
helpful.
• Engage the family in developing the plan, solicit their input and agreement.
• Build on strengths; there are always some. These provide a valuable way to
engage parents.

• Encourage informal supports (e.g., family, friends; invite
fathers to office visits). This is where most people get their support,
not from professionals. Consider support available through a
family's religious affiliation.
• Consider children's specific needs. Too often, maltreated
children do not receive direct services.
• Be knowledgeable about community resources, and facilitate
appropriate referrals.
• Provide support, follow-up, review of progress, and adjust the
plan if needed.
• Recognize that maltreatment often requires long-term
intervention with ongoing support and monitoring.

Guardian and Wards Act, 1890
 Factories Act ,1954
 Hindu Adoption and Maintenance Act, 1956
 Probation of Offenders Act, 1958
 Bombay Prevention of Begging Act, 1959
 Orphanages and Other Charitable Homes (Supervision and Control) Act, 1960
 Bonded Labour System (Abolition) Act, 1976
 Immoral Traffic Prevention Act, 1986
 Child Labour (Prohibition and Regulation) Act,1986
 Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act, 1987
 Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994
 Persons with Disabilities (Equal Protection of Rights and Full Participation) Act, 2000
 Juvenile Justice (Care and Protection of Children) Act, 2000
 Commission for Protection of the Rights of the Child Act, 2005

 Infanticide (Section 315)
 Abetment of Suicide: Abetment to commit suicide of minor (Section 305)
 Exposure and Abandonment: Crime against children by parents or others to expose or to
leave them with the intention of abandonment (Section 317)
 Kidnapping and Abduction: Kidnapping for extortion (Section 360)
Kidnapping from lawful guardianship (Section 361)
Kidnapping for ransom (Section 363 read with
Section 384),
Kidnapping for camel racing etc. (Section 363)
Kidnapping for begging (Section 363-A)
Kidnapping to compel for marriage (Section 366)
Kidnapping for slavery etc. (Section 367)
Kidnapping for stealing from its person: under 10 years of age
only
(Section 369)
 Procurement of minor girls by inducement or by force to seduce or
have illicit intercourse (Section 366-A) .
Selling of girls for prostitution (Section 372) h) Buying of girls for
prostitution (Section 373)
 Rape (Section 376)
 Unnatural Sex (Section 377). www.dnbpediatrics.com

SCHEMES AND PROGRAMMES ON CHILD PROTECTION
 A Programme for Juvenile Justice for children in need of care and
protection and children in conflict with law. The Government of India
provides financial assistance to the State Governments/UT Administrations
for establishment and maintenance of various homes, salary of staff, food,
clothing, etc. for children in need of care and protection and juveniles in
conflict with law. Financial assistance is based on proposals submitted by
States on a 50-50 cost sharing basis.
 An Integrated Programme for Street Children without homes and family
ties. Under the scheme NGOs are supported to run 24 hours drop-in shelters
and provide food, clothing, shelter, non-formal education, recreation,
counselling, guidance and referral services for children. The other
components of the scheme include enrolment in schools, vocational
training, occupational placement, mobilizing preventive health services and
reducing the incidence of drug and substance abuse, HIV/AIDS etc.
 CHILDLINE Service for children in distress, especially children in need of
care and protection so as to provide them medical services, shelter, rescue
from abuse, counseling, repatriation and rehabilitation. Under this initiative,
a telephone helpline, number 1098, runs in 74 urban and semi-urban centres
in the country.
 Shishu Greha Scheme for care and protection of
orphans/abandoned/destitute infants or children up to 6 years and promote
in-country adoption for rehabilitating them.

 .
 Rajiv Gandhi National Creche Scheme for the Children of Working Mothers in the
age group of 0- 6 years. The scheme provides for comprehensive day-care services
including facilities like food, shelter, medical, recreation, etc. to children below 6 years
of age.
 Pilot Project to Combat the Trafficking of women and Children for Commercial
Sexual Exploitation in Source and Destination Areas for providing care and
protection to trafficked and sexually abused women and children. Components of the
scheme include networking with law enforcement agencies, rescue operation, temporary
shelter for the victims, repatriation to hometown and legal services.
 National Child Labour Project (NCLP) for the rehabilitation of child labour. Under
the scheme, Project Societies at the district level are fully funded for opening up of
Special Schools/Rehabilitation Centres for the rehabilitation of child labourers. These
Special Schools/Rehabilitation Centers provide non-formal education, vocational
training, supplementary nutrition and stipend to children withdrawn from employment.
 INDO-US Child Labour Project (INDUS): The Ministry of Labour, Government of
India and the US Department of Labour have initiated a project aimed at eliminating
child labour in 10 hazardous sectors across 21 districts in five States namely,
Maharashtra, Madhya Pradesh, Tamil Nadu, Uttar Pradesh and NCT of Delhi.

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