INTRODUCTION
The phrase “Child Abuse and Neglect” has been commonly used since the first reported case of the Battered Child Syndrome that today we hardly think of abuse without the other. Unfortunately, in the recent years, abuse has taken the centerfold of publicity while the concept of neglect has been lost. The rapid rise in the prevalence and incidence of sexual exploitations of children in the last decade has further pushed the issues of neglect to the background. This unintended “de-emphasis” has reached to an extreme apathy that today the litany of child neglect has insidiously caused untold catastrophe in our society. There is the need to bring back this issue of child neglect to its rightful place in the total care of the child.
Traditionally the word “abuse” was equated with physical aspect of maltreatment, while “neglect” simply meant our failure to meet certain basic needs of the child. While the previous modules deals on child abuse, this module will on the following aspects of child neglect
1. Emphasis on responsibility, incidence, definition, and overall scope of the problem
2. Clarify terminology and semantics as they relate to child neglect with special emphasis on various interpretations and perception of causes and outcomes.
3. Present an epidemiologic algorithm with emphasis on manifestation,responsibility and prevention of child neglect
4. Discuss the role of law, including enforcement, lawyers, courts, legislation and reporting
5. Identify current social and economic issues that adversely affect our care of our children
CHAIN OF EVENTS
CLINICAL PRESENTATION
Present History
This is a case of a 6 year old male child presenting at the Emergency room because of seizures
9 hours PTA, was noted with behavioral changes,
2 hrs PTA ( 12MN) noted to be restless and turned from side to side, still with vomiting,
1 hr PTA, noted stiffening of lower extremities, and became unresponsive . The symptoms persisted hence the admission.
Patient allegedly drunk wine with unknown visitors during a birthday party after which vomiting was noted for 2 times. The patient slept most of the time.
Past History – no previous hospitalization
Family Hx – father is a known alcoholic
Social History – adopted child given by younger sister of the present surrogate mother claims that the patient occasionally took ‘Tuba”, a native coconut wine while having drinking spree at home with his uncles since 3 years old
Stepfather, is 50 year old, a welder and alcoholic
Stepmother is 42 years old , plain housewife
Other step brothers ( siblings) are young teenagers ( 3)
all are drug addicts , and alcoholics
Immunization – complete primary immunization
Developmental Milestone – at par with age
Physical Examination
Comatose, in respiratory distress with decerebrate rigidity
HR- 170/ min RR – 60-70/min (with episodes of apnea interposed with rapid deep breathing)
Temp 39C
HEENT – Pupils 2mm ERL(+) Alcoholic breath
CHEST – Subcostal retractions Harsh Breath sounds
ABDOMEN – Flat, soft (-) organomegally
EXtremities Full pulses
Neurology
Comatose
Decerebrate
Hyperflexia
(+) Toes – self fanning
(+) Ankle clonus
Admitting Diagnosis : Alcoholic Intoxication
NEUROLOGICAL REFERRAL NOTES
Seen and examined a 6 year old male, Marcos Mervin from Guiwan, admitted for the first time because of seizure.
(+) history of induced alcoholic drinking spree involving “Tuba”, and San Miguel Gin with uncles the night PTA. Amount was undisclosed.
This child became the object of fun for the stepbrothers who induced him to drink. When he became drunk, his staggard base walk became the source of fun and redicule.
(+) vomited several times the morning PTA then followed by seizures
Physical Examination
Semi-comatose to coma , febrile , dyspneic
HR – 150/mi RR – 60/min T- 39C
Posturing – decerebrate
Cranial Nerves
Pupils 2-3 mm ERL
(+) dolls eye
(?) corneal reflex
(-) facial asymmetry
(+) gag reflex
DTR – upper extremities + 3
Lower Extremities –difficult to assess because of spasticity
Fanning of toes bilateral
DIAGNOSIS – Coma secondary to alcoholic intoxication
LABORATORY
Glucose – 5.66 mmol/l
Urea 3.84 mmol/l
Creatinine 66.4 mmol/l
K 4.4 mmol/l
SGOT 100 U/L
HGT – 0 Rpt test after Tx – 80g/dl
COURSE IN THE WARD
Stayed in the hospital for less than 24 hrs. Had coffee ground vomitus signifying Gastrointestinal bleeding. He had another prolonged seizure and subsequently went into Cardio-Pulmonary arrest. The surrogate mother refused cardiopulmonary resuscitation.
TERMINAL OBJECTIVES
At the end of this module, the students will be able to
1. Identify the signs and symptoms of a neglected child
2. Provide medical evaluation and treatment of injuries resulting from the neglect
3. Take emergency measures needed to protect the child from further injuries resulting from neglect by
a. arranging for custodial care
b. hospitalize or place in emergency foster care
c. refer for police care
d. educate the caregivers
4. Provide an accurate and complete medical evaluation and record , document,protect legal evidence
5. Provide and maintain a follow-up care
6. Know how to give evidence in court
ENABLING OBJECTIVES
Given the case of a child suspected to be a victim of neglect, the student should be able to treat and care for a neglected child . To achieve this, the students should develop the following competences categorized under the following headings
1. Awareness and Validation of the problem
2. Prevention
3. Diagnosis and management
4. Intervention and treatment
5. Society and the wider issues of the problem
A. AWARENES AND VALIDATION
1. Know the Incidence and prevalence of child neglect in the region
2. Identify Barriers to care of a neglected child
3. List the Myths about child neglect
4. Discuss child neglect issues in the context of a diverse Filipino Society
5. Explain the Family life Cycle as framework for child neglect
6. Identify the causes , prevention and treatment of child neglect
7. Identify the Population at risk to perpetuate child neglect
8. List the available Community resources for prevention, treatment, intervention in child neglect
B. PREVENTION
1. Explain the strategies for primary, secondary, and tertiary prevention of child neglect
C. DIAGNOSIS AND IDENTIFICATION
1. Know how to ask screening question for the detection and diagnosis of child neglect
2. Define risk factors for child neglect in a clinical setting
3. Elicit history from the victim, family, perpetrator
4. Perform the necessary and appropriate Physical Examination
5. Assess mental and developmental status of victims
6. Recognize incongruities between the History and P.E. findings
7. Identify which physical findings that are most likely due to intentional neglect
8. Assess the degree of victimization
D. INTERVENTION AND TREATMENT
1. Apply appropriate intervention techniques in dealing with victims, their families and the perpetrators of child neglect
2. Do accurate documentation and preservation of evidences, reporting and referring cases of child neglect to the appropriate agency for specialized care
3. Demonstrate the ability to network with other health care team with other special training
4. List the Legal and Ethical Issues of reporting, interfacing with legal system and the chain of custody of child neglect
5. Explain the Responsibility of healthcare giver to protect the child
6. Show the ability to prepare testimony for court
E. SOCIETY AND HEALTH CARE
1. Discuss the Economic cost of child neglect on the society as a whole
2. Identify High Risk social and environmental factors for Child neglect
3. Identify broader determinants in the psycho- pathogenesis of child neglect
EXPECTED LEARNING ISSUES
1. In which settings do children confront as especially high risk for child neglect?
2. Which features in the history most reliably point towards a case of child neglect?
3. Which features in the physical examination findings most reliably point to a case of child
neglect? abuse?
4. Given the possibility that the child has been physically neglected,what are the responsibilities of the health care provider in regards to reporting , protecting the child, preparing for testimony in court , and documenting and preserving evidences of child neglect ?
5. How do health professional achieve to maintain a therapeutic alliance with the family for continued support care?
TUTORIAL OVERVIEW OUTLINE
Session 1 : Focus – What is Wrong?
Discussion Topics
Identification and definition of patients problems
Mechanism of seizures, apnea, coma
Ranking of the hypotheses
Expected Learning Issues
Anatomy of the brain and cranium
Basic mechanism of alcoholic intoxication and complication
Neurologic examination in a comatose patient
Glasgow coma scale
Session 2 : Focus – What are the evidences validating the hypotheses?
Discussion Topics
History taking and Physical Examination
Validation of the hypotheses
Analysis of the case in the light of new information
Final diagnosis and synthesis of the case
Discordant history and physical findings
Degree of victimization
Learning issues
Biochemical alteration in alcoholic intoxication
Session 3: Focus – Why? What lead to this? Who did it?
Discussion Issues
The need to explore the broader context of behavioral pathogenesis of this particular child abuse/neglect
Dysfunctional Home – What is it?
Neglect , deprivation and Abuse- What is the difference?
Learning Issues
Psycho-pathology of the perpetrators
Incidence and prevalence of child neglect
Populations at risk
Session 4 : Focus: Who gets it, and How is it prevented or Fixed
Discussion Issue
Barriers to the health
Societal myths about child abuse/ neglect
Dual responsibility of physician – care of the patient/care of the perpetrator
When and how to intervene
How to access to the community resources for child care
Importance of prevention
Strategies for Primary, Secondary and Tertiary prevention
Learning Issues
Legal and ethical issues of reporting in child neglect
Interface with legal system – chain of custody restraining orderscivil and criminal actions and proceedings
Identify other professionals involved in the care of the needs of the victims, family, perpetrators (Multidisciplinary team Work)
Session 5 : Focus: Now what? Is there anything we can do for the child? Family? Abuser ?
Discussion Issue
Concern for child safety
Hospitalization or safe house placement
Advocacy for stronger child protection laws
Rehabilitation of the neglected child
Learning Issues
What are the current laws protecting the child from neglect? Are they sufficient?
CLINICAL PRESENTATION
This is a case of a 6 year old male child presenting at the Emergency room because of seizures 9 hours PTA, was noted with behavioral changes,2 hrs PTA ( 12MN) noted to be restless and turned from side to side, still with vomiting, 1 hr PTA, noted stiffening of lower extremities, and became unresponsive . The symptoms persisted hence the admission.
Patient allegedly drunk wine during a birthday party after which vomiting was noted for 2 times. Thereafter the patient slept most of the time.
TUTORIAL OVERVIEW – TUTORS COPY
SESSION 1
Focus – What is Wrong?
OVERVIEW
This session is meant to bring into discussion the need for recognizing child neglect .The recognition of any form of child neglect starts in the willingness of the physician to acknowledge its existence and to consider it in a differential diagnosis for any child presenting with alcoholic intoxication.
Discussion Topics
Identification and definition of patient’s problems
Basic Mechanism of alcoholic intoxication
Ranking of the hypotheses
Expected Learning Issues
Review of the Neurologic signs and symptoms
Basic mechanism of intra-cranial bleed/Coma secondary to alcohol intoxication
Contrast between intentional and accidental injury
Neurologic examination
Trigger Questions
1. How would you like to approach this case?
2. What are the problem/s of this infant? What could explain the symptoms?
3. What does weak cry in an infant signify? Unresponsive to noise?
4. Based from the chief complain, what is/are your hypotheses to this case?
5. Why did you consider __________ as one of your hypothesis?
SESSION 2
Focus : What are the evidences validating the hypotheses?
OVERVIEW
History is the initial crucial step in establishing intentional neglect. Physician should be sensitive and skilled enough to obtain the necessary history from the care givers. As in any clinical setting , honesty and straight forwardness on the part of the physician need to be balanced with objectivity and empathy. Most parents are often distressed themselves, and much of child neglect may have been unintentional. Parents too may need to feel that they are in a supportive environment and appropriate language should be used.
DISCUSSION ISSUES
History taking and Physical Examination
Validation of the hypothesis
Discordant history from the physical findings
Analysis of the case in the light of new information
Pathognomonic pattern of intentional neglect
Physical and psycho-social development of the child
Final Diagnosis and Synthesis of the case
Types of Intra-cranial Injury that can suggest intentional neglect
Degree of victimization
Hospitalization or safe house placement
EXPECTED LEARNING ISSUES
Types of injury with high index of specificity due to child neglect
Trigger Questions
What other information would you need to help validate your hypotheses?
Is the history enough to explain the symptoms of this case? Is it compatible with the physical finding?
How do you diagnose intentional injury?
SESSION 3
Focus – Why? What lead to this? Who did it?
OVERVIEW
The socio-economic and cultural factors in conjunction with internal family stresses pressing on the family unit plus a triggering situation can all lead to child maltreatment including neglect. It is therefore important for the students to learn the need to explore these broader determinants of the behavioral pathogenesis in child neglect. Expectedly, this latter skill will lay the foundation for appropriate solution to address this hidden and ignored health problem.
DISCUSSION ISSUES
The need to explore the broader context of behavioral pathogenesis of child neglect
The socio- economic & cultural factors causing family stress ( diversity of culture)
Social situational stress as Triggering situations for neglect
Dysfunctional Home
Concern for child safety under surrogate “nanny care”
Family life cycle – and behavioral aberrations
Neglect , Deprivation and Abuse- What is the difference?
EXPECTED LEARNING ISSUES
Psycho-social pathology of the perpetrators
Incidence and prevalence of child neglect
Population at risk
Trigger Questions
1. What could have led to this incident? Why?
2. Is this recent? or has this been going on?
3. What is a dysfunctional home?
4. Is this a child neglect or child abuse? Is this child rejected?
5. What is the risk for child neglect under “nanny’s” care?
6. What is the difference between abuse and neglect? or rejected?
7. Is it true that neglect child can end up into a neglecting parents ?
SESSION 4
Focus: Who gets it, and How is it prevented or Fixed?
OVERVIEW
The diagnosis of child neglect almost always leads to physician anxiety about being involved in a civil case.. Physician may hesitate because the doctor-family relationship might be compromised, office time and revenue might be lost, or involvement with the police or court system is feared. Because of these barriers, physicians do not get involved with advocacy against child neglect . However, if the abuse is not considered or recognized, a child may remain in further danger.
Physicians have both the legal and ethical responsibility to report any suspected child neglect to a child protection service agency. The interdisciplinary approach to assessment, intervention and case management is important for the protection of the child. The physician should know about the reporting process and what to expect after the report is made.
DISCUSSION ISSUES
Barriers to the diagnosis and care
Societal myths about child neglect
Dual responsibility of physician – care of the victim care of the abuser
When and how to intervene
How to access community resources for help and networking
Importance of prevention
Strategies for Primary, Secondary and ertiary prevention
Economic Cost of child neglect
EXPECTED LEARNING ISSUES
Legal and ethical issues of , reporting , evidence preservation of child neglect
Interface with legal system – chain of custody restraining orderscivil and criminal actions and proceedings
Identify other professionals required to address the needs of the victims, family, perpetrators (Multidisciplinary Team Work)
Trigger Question
Why are doctors hesitant to handle cases of child physical abuse?
Child neglect?
What can doctors do to help abused/neglected child?
Is child neglect a social, medical or legal issue?
How extensive is this problem?
Can this social issue be prevented? How?
What do you think about the street children. Are these a type of child abuse? Neglect? or social survival?
What could be done in the political and legal level to help solve Child neglect?
SESSION 5
Focus: What more can we do for the child? the family? the abuser
OVERVIEW
Traditionally, the role of the physician in child neglect has mainly been centered on detection ( diagnosis ) , medical treatment and referral. However this role can still be expanded to cover the area of prevention and follow up care. Physicians can and even help evaluate the status of the other siblings. They can be involved in advocacy for more stringent laws against child neglect or be involved in a hospital protection team, or they may participate in community projects in promoting appropriate child care. Physicians should also be involved in discussing issues of child-parent bonding with parents who come for regular consultations, review home and child management and to suggest strategies to strengthen parents capabilities in coping with stress, in particular , caring for children with special needs. Furthermore, it is often that the physician is the only professional who maintains contact with the family after all other care is terminated. This relationship can be maintained and even encouraged as a critical link to help parents overcome family crisis.
DISCUSSION ISSUES
Evaluation of the status of the other siblings
Advocacy for stronger child protection laws
Hospitalization or Safe House placement
Psychiatric treatment of the child and the abuser
Social Accountability of doctors
EXPECTED LEARNING ISSUES
Who has the right of custody for the abused and neglected child?
What are the current laws protecting the child?
Review the legal decisions of the recent celebrated case “ the Nanny trial” Louise Woodward, the 19 year old English nanny trial for shaking to death a baby under her care.”
Trigger Questions
Can child neglect be prevented? How?
How can child neglect prevention be achieved in an OPD consultation
What would your management for this child include? The family? Other siblings?
If this child survives this physical insult, what aftermath impact has physical neglect on the child later? Is it true that a child may just simply forget about it?
TEST CASES FOR FURTHER STUDENT DISCUSSION
CASE 1 : RUBY MAE TAMAYO
CASE HISTORY : PATIENT PRESENTATION
Chief Complaint
Ruby Mae, a 2 year-old female, is brought to you by her mother who reports that the child drank some kerosene and now is vomiting and has a fever.
Tutor’s prompt
1. Make a list of Ruby Mae’s problems.
2. For each major problem, list your hypothesis, as to the cause, and suggest a mechanism by which that hypothesis can lead to the presenting problem.
3. Any additional information you need from Ruby Mae history? From her parents? Give a rationale why you are asking such questions?
History of the Present Illness
A day before admission, Ruby Mae accidentally drank kerosene placed in a bottle of Coca-cola, the amount of which is unknown. She was given a sweetened coffee after which she had 3 bouts of vomiting.
She was then brought to a local health center and observed, and later send home with oral ampicillin.
Recurrence of the vomiting associated with high grade fever prompted the parents to bring the patient to this hospital for medical care. PAST MEDICAL HISTORY – + BFC (Benign Febril Convulsions)
TRIGGER QUESTIONS
1. How did the new information from the interview modify or help you re-rank your hypothesis?
2. What Physical examination findings would you like to know? Why ?
3. Does this case constitute neglect? How do you justify your answer? Was the mother neglecting this child?
4. Was the health center neglectful in the care of this child?
Physical Examination
General survey Fairly developed , poorly nourished in Respiratory Distress
HR: 140/min RR: 63/min T : 39.0C Wt: 8Kg
HEENT Pinkish conjunctivae, anicteric sclerae, (-) Nasal congestion
(+) Alar flare, supple neck
CHEST Symmetrical chest expansion, (+) Intercostal rectractions
(-) Chest indrawing (+) Rales on both Lung Fields
Resonant on percussion
HEART Tachychardic, but regular Rate and Rhythm (-) Murmur
ABDOMEN Soft, flat, no organomegaly
EXTREMITIES : Good strong peripheral pulses, pink nail beds
Neurologic Examination:
Conscious, coherent, obeys simple commands
CN pupils equal reactive
EOM full
Tongue- Midline
No Facial Assymmetry
Meningeals – Supple Neck
Reflexes – Normal reflexes
(-) Babinsky
TRIGGER QUESTIONS:
1. How do these PE findings modify your hypothesis or refine your thinking about Ruby Mae’s problems?
2. What additional information do you need? Explain your reasoning in requesting for this additional information.
3. Explain and demonstrate a standard PE (Physical Examination) on patients with poisoning. What organ systems will you focus on? Why?
DIAGNOSTIC TEST
1. Chest X-ray -Diffuse bilateral patchy pneumonic infiltrates are noted.
Heart and rest of the thoracic structures are unremarkable.
2. CBC Hct : 0.29 Hgb 9.6 gm%
WBC 12,000 Seg : 0.77 Lymp 0.22
Eos : 0.01
Trigger Questions
1. How does the diagnostic test information guide you in your diagnosis?
2. What are your treatment options?
3. What goal outcomes might you expect in managing this patient?
4. What incidental findings did you pick up in the tests? Are they significant?
PROFESSIONAL SKILL STRAND
KEROSENE POISONING
This is a Chest X-ray of another child with kerosene ingestion.
Make an evaluation of this X-ray. Start from the bone structures then proceed to study the lung parenchyma.
What is your radiological reading of this X-ray?
CASE 2: JENNY PANTALEON
Trigger 1
Jenny Pataleon, a 5 year old student from Tolosa, was admitted for the first time due to burns sustained from a thermal accident 3 hours PTA. The patient was trying to light a kerosene lamp with a match stick. Unfortunately the lamp had a leak and on striking the match, the whole lamp caught fire and burst right in front of her.
Could this incident have been prevented? How?
Is there evidence of neglect here?
Case #2 Jeny Pantaleon
Trigger 2
PHYSICAL FINDINGS
Admitted is a 5 year old girl conscious and in pain, stretcher borne. The burn includes the face, neck, forearm chest and abdomen, and thighs.
Vital Signs:
BP – not taken, both arms severely burned
RR- 35 deep with intercostal retractions
HR- 102/min regular tachycardic
TRIGGER QUESTIONS
To what extent is the burns? How is it established?
What is first degree burn? Second? Third Degree burns?
What complications might you expect? Why?
What would your initial management be?
Case #2 Jeny Pantaleon
Trigger 3
COURSE IN THE WARD
Jenny was admitted and fluid hydration was started. She was given ATS together with Tetanus Immunoglobulin. Antibiotics were immediately started and necrotic tissues were debrided under general anesthesia. Escharatomy was likewise done to facilitate chest movement. Local care of the exposed raw wound was done. Hyper alimentation by enteral feeding was started.
Case #2 Jeny Pantaleon
Trigger 4
Behavioral/Population Perspective
Like drowning, most burns can be prevented. Be sure to address the following issues.
Trigger Questions
1. Is it the responsibility of the manufacturer to make their products as safe as possible to prevent accidents? Could the manufacturers of lamps do anything to make them safer?
2. Is there a need for fire safety instruction in your community? How should it be done?
3. How do you handle the emotional stress in a patient who is disfigured from a burn?
4. What role does reconstructive plastic surgery play? What about its cost?
5. Is this a case of child neglect? What is the responsibility of the parents? The manufacturer?
6. What constitutes child neglect?
Case #2 Jeny Pantaleon
Trigger 5
Professional Skills Strand
Be sure to discuss the following topics:
1. Estimating burn extent; The rule of nine’s.
2. Fluid replacement in burns:
Type of fluid.
Amount of fluid.
Rates of infusion.
3. Hyperalimentation
Its rationale, indications, benefits, risks.
How to calculate needs
4. Escharotomy and fasciotomy
Indications
Contradictions
Risks
Benefits
When, where and how to perform.
CASE 3: ROBERTO LIMEN
Chief Complaint
Roberto Limen, a 2-year old male is brought to the ER with a scald type of burn to his buttocks.
Further History
The parents report that a glass of hot water spilled on the child as the latter tried to pull it from the table.
Physical Examination
General: Crying, fretful
Vital signs: normal for age.
Skin: Bright red burn over buttocks and posterior thighs with some blistering.
Case #3 Roberto Limen
Some points to consider to bring in the issues of child neglect /abuse
1. Would you consider this an accident or child neglect?
2. How should you handle suspected cases of child abuse presenting as child neglect or accident?.
3. The law often place the responsibility of neglect on the parents. Do you think this is right?
4. What is the responsibility of society to intervene in personal & Private family matters?
5. What are your responsibilities for child protection advocacy?
6. Child neglect is said to occur when those responsible for meeting the the needs of the child fail to do so. Does this definition mean the manifestation of neglect must occur or just the failure to meet their need?
CASE 4: TWO BROTHERS
Two small children were brought to the emergency room on a Saturday afternoon. Both had evidence of having been bitten by a neighbors dog.
Were these children neglected?
What are the legal issues around this case?
CASE 5: MALNOURISHED CHILD
An infant was brought in and referred by a social worker. The infant was severely malnourished. On you evaluation you noted a cognitive problem in the mother. It was further learned that the other siblings are street children.
Is there child neglect here? Was the mother neglectful here?
Poverty does not equal neglect or vice versa. Do you agree with this statement?
Does a given outcome in a poor child mean one thing and a well to do child another?
Does neglect involve intent? Or can neglect be established without intent?
Does the term neglect in any way imply intent?
TUTORS NOTES ON ALCOHOL INTOXICATION
Alcohol is rapidly absorbed from the stomach and transported to the liver and metabolized by two pathway.
1. Primary pathway – form acetaldehyde which leads to fatty liver
2. Utilized at high serum alcohol levels involving the mircosomal system of the liver in which the cofactor is reduced ( NADPH) – leading to decrease metabolism of drug that shares this system ___ leading to accumulation and subsequently toxicity.
Alcohol acts primarily as a central nervous system depressant
At very high serum level , respiratory depression occurs
Its inhibitory effect on pituitary ADH release responsible for its diuretics effect
GIT complication – vomiting, epigastric pain
Blood analysis
Ø 200 mg/dl – at risk of death
Ø 500 mg/dl – associated with fatal outcome
