Abuse and neglect are commonly encountered in both children and the elderly. It occurs when a caregiver, whether through willful action or lack of appropriate action, causes harm or distress to the person under their care. The victims can be encountered in different healthcare settings and may be at risk of various health consequences. The optimal outcome for these individuals may depend upon early recognition of the signs and symptoms of abuse and/or neglect and prompt evaluation. The following activity will provide an overview of the clinical features, evaluation, and approach to a patient with suspected abuse or neglect.
Abuse and neglect of the child and the elderly are often perpetrated by the parent or caregiver responsible for their care. This can include physical abuse, sexual abuse or exploitation, psychological abuse, neglect or abandonment, and confinement.
Predisposing factors for child abuse and neglect are multifactorial, ranging from socioeconomic stressors to harmful cultural practices all contributing to the various degree of vulnerability among the world child population. Some of the identified risks are as follows:
The following factors predispose the elderly to abuse and neglect:
The prevalence of child abuse and neglect varies widely. Available estimates suggest that as much as a quarter of the world adult population may have experienced some form of abuse or neglect during childhood with a slightly higher incidence in female subjects.
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 41,000 cases of child homicide occur yearly.
Abuse of the elderly is equally common. In the United States of America, 1 in 10 people older than the age of 60 may have experienced some form of abuse, amounting to about 5 million cases per year.
Child Abuse and Neglect
Depending on the age of the child, historical information is often primarily obtained from the caregiver and the comments provided by the patient (especially in older children and adolescents). Children who suffer from abuse or neglect may present with typical presenting complaints (i.e. vomiting). Therefore, for the clinician who sees pediatric patients regularly, it is important to keep child abuse or neglect in the differential diagnosis during every visit to enhance the likelihood of recognition.
The approach to history taking should be structured, systematic, with the flexibility to allow different lines of questions, and thus similar to how a clinician obtains a routine history. This will not only ensure rapport with the patient and the caregiver, but it enhances the ability of the clinician to quickly investigate any historical and physical features that are concerning for child abuse or neglect.
There are various historical features that should raise the suspicion for abuse.
1. Lack of history of trauma in a pediatric patient with severe injuries
2. History describing the mechanism of injury inconsistent with the child's developmental level
3. Unexplained delay in seeking care before presenting to a medical provider
4. History describing injuries attributed to household pets or other young children
5. The initial history is vague or changes amongst different caregiver accounts
The physical examination should be routine, systematic, and focus on findings that may indicate an underlying etiology of the child's initial complaint, including the possibility of child abuse or neglect. This begins with the general appearance of the patient and how they interact with their caregiver. This may include but is not limited to lack of interaction between the patient and the caregiver (i.e. patient not seeking comfort or caregiver not offering comfort), not appreciating the severity of the patient's condition, assigning blame to the child for their injuries or illness, treating the patient differently than the other children in the room, and if the patient displays fear towards the caregiver present.
There are various presenting features that should raise the suspicion for abuse. These include:
1. Bruises in infants less than 6 months (infants not yet freely mobile), bruises situated away from bony prominences, and bruises with a unique shape (like the shape of an object) are highly suggestive of abuse
2. Human bite marks
3. Oral injuries (including frenulum tears, lip lacerations, tongue lacerations, fractures; especially in infants)
9. Intentional burns (scalds from hot tap water, burns that resemble the shape of burning objects, cigarette burns)
1. Nonspecific symptoms (abdominal pain, fecal incontinence, constipation)
2. Genital bruising and/or bleeding
4. Behavioral or personality changes
5. Inappropriate behavior especially of the sexual nature (for example, an unusual interest in genitals of other children or even adults)
Emotional abuse and neglect
1. Poor hygiene
2. Signs of malnutrition (child may refuse meals)
3. Child may appear withdrawn with inadequate social interaction
4. Developmental milestone delays (such as speech and motor delays)
Adult Abuse and Neglect
Depending on the patient's underlying health condition, historical information may be obtained from the caregiver and the comments provided by the patient. If possible, it is best to solicit the history from the patient and the caregiver separately.
The approach to history taking should be structured, systematic, with the flexibility to allow different lines of questions, and thus similar to how a clinician routinely obtains a history. This will not only ensure rapport with the patient and the caregiver, but it enhances the ability of the clinician to quickly investigate any historical and physical features that are concerning for elder abuse or neglect.
There are various historical features that should raise the suspicion for abuse. These include:
1. Mechanism of injury that is implausible based on the patient's condition
2. History is inconsistent, vague or different between the patient and caregiver
3. Delay in seeking medical attention
4. Past history of frequent injuries or unexplained visits to the emergency department
6. Caregiver answers questions for the patient
7. The patient is reluctant to answer questions
The physical examination should be routine, systematic, and focus on findings that may indicate an underlying etiology of the patient's reason for the visit. This begins with the general appearance of the patient and how they interact with their caregiver. The clinician should observe the patient for any signs of fear, anxiety, infantile behavior, poor self-esteem, and/or mistrust in the presence of the caregiver. Caregivers may be emotionally abusive.
There are various physical features that should raise the suspicion for abuse. These include:
1. Unexplained signs of injury: Bruises, burns, scald, fracture, signs of restraints on the hands and feet
2. Bedsores (pressure ulcers)
3. Poor hygiene
4. Signs and symptoms of dehydration, malnutrition, or unexplainable weight loss
5. Emotionally withdrawn and showing signs of depression
6. Refusal to take routine medications or drug overdose
7. Hair loss
8. Broken teeth
10. Evidence of trauma on a genitourinary exam or vaginal bleeding
When abuse or neglect is suspected in a patient of any age, the clinician should order testing as indicated by the history and physical examination. These may include:
3. Global skeletal surveys in children that images subtle metaphyseal, rib, and other injuries specific for abuse
4. Computed tomography of the abdomen to rule out the presence of any intraabdominal injuries particularly duodenal or pancreatic injuries, but also liver, spleen, kidney, adrenal gland, mesentery, and/or intestinal injuries
5. Ophthalmologic evaluation to rule out the presence of retinal hemorrhages
2. Toxicology Testing to rule out the presence of malicious administration of substances
4. Serum Lipase to rule out pancreatic injury
5. Hepatic Function Panel to rule out the presence of intraabdominal injury
9. Urine organic acids to rule out the presence of metabolic conditions such as glutaric acid type I
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.
Management of abuse and neglect involves:
There are various conditions where the clinical manifestations may be mistaken for child abuse. The clinician must be familiar with these diseases as some may require prompt initiation of appropriate therapy for the actual underlying condition and to avoid unnecessary evaluation for child abuse.
This is summarized below by the clinical findings:
4. Intracranial Hemorrhage
For elder abuse and neglect the following conditions should be considered:
Elder abuse and neglect are associated with increased morbidity (particularly the development of depression, dementia, cognitive impairment, loss of functional capacity) and increased mortality. Child abuse and neglect are associated with lifelong medical, psychological, and social consequences as well as increased risk of future abuse.
Parents and caregivers of children and the elderly should be counseled on the common signs and symptoms indicative of child and elder abuse and neglect.
For the child, parents and caregivers should be counseled to observe for unexplained bruises or markings, oral injuries, change in behavior (i.e. withdrawn in a young child, excessive crying in an infant), genitourinary abnormalities, behavioral change, inappropriate behavior (especially of a sexual nature).
For the elderly, the caregiver or family member should observe for unexplained injuries (including bruises, burns, fractures), pressure sores, change in behavior, weight loss, lack of food, dehydration, urinary or fecal incontinence, genitourinary injury, and poor hygiene.
If a caregiver is having difficulty providing care, they should be advised to notify a physician or nurse. The physician or nurse can counsel the caregiver, especially if they are the primary caregiver of the child or elderly person, in how they can obtain support or help so that they are not overwhelmed.
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.
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.
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.
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.
Despite better awareness of the problem of child abuse, healthcare workers still miss many cases of abuse and neglect. 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]
Elder abuse and neglect is also a major public health concern. Clinicians must have a high index of suspicion and distinguish the clinical features of aging from elder abuse and neglect. In patients with risk factors, this may require the creation and use of screening questions (by all professionals), prompting further evaluation, and referral to the appropriate adult protective agency.[Level V]
Multidisciplinary medical response teams dedicated to elder abuse and neglect may be utilized to help evaluate suspected patients of abuse or neglect and confirming the presence of abuse. [Level 5]
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