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CHAPTER 34

Injuries from Child Abuse

AB (Sebastian) Van As
Dorothy V. Rocourt
Benedict C. Nwomeh

Introduction • unexplained injuries;
Child abuse and neglect can be broadly defined as the maltreatment of • discrepant histories;
children by parents, guardians, or other caretakers. The main responsi-
bilities of all health care workers (HCWs) are the detection, treatment, • delay in seeking medical care;
and reporting of child abuse. Contrary to common belief, child abuse • alleged self-inflicted injury;
is not a new phenomenon. Many reports indicate that child abuse has
been around since early times and is present in all cultures. The child is • alleged third-party–inflicted injury;
weak, vulnerable, and an easy target for abuse. The smaller the child, • repeated injuries;
the greater the danger of abuse and the higher the risk for fatal outcome.
Children in low-income countries are particularly vulnerable to death • sexualised behaviour; or
from abuse. Africa has the highest rates of homicide for children younger • sexually transmitted disease (STD).
than 5 years of age, at 17.9 per 100,000 for boys and 12.7 per 100,000
for girls—more than six times the incidence in Western countries. The Types of Child Abuse
1
magnitude of the problem is obscured by differing legal and cultural There are several types of child abuse, as outlined here.
definitions of abuse and poor reporting and recording of cases. 1. Physical abuse or nonaccidental injury denotes injuries inflicted by
Definition of Child Abuse the caretaker.
In Africa, child-rearing practices often vary from those in Western 2. Child sexual abuse is the use of a child for sexual gratification. Note
countries; therefore, caution is needed in determining what constitutes that this is a broader term than child rape. Besides sexual intercourse it
abuse or neglect. For example, some cultures accept male as well as also includes:
female circumcision, but others might consider it as clear child abuse. • touching, fondling, or other inappropriate contact with the child’s
A useful approach is one that defines child abuse as abuse to an extent genitals or breasts;
that is not acceptable in a particular culture. However, this can easily
• masturbation of a child by an adult or vice versa and masturbation
lead to problems. According to the World Health Organization (WHO),
of an adult in the presence of a child;
“child abuse or maltreatment constitutes all forms of physical and/or
emotional ill-treatment, sexual abuse, neglect or negligent treatment or • body contact with adult genitals;
commercial or other exploitation, resulting in actual or potential harm • exhibitionism; and
to the child’s health, survival, development or dignity in the context of
a relationship of responsibility, trust or power”. 2 • pornography, including photography and erotic talk.
Health Care Workers’ Roles in Child Abuse Of note, most of these abuse acts will leave no physical signs on the victim.
The roles of health care workers are to: 1. Failure to thrive due to nutritional deprivation most commonly
• recognise child abuse; occurs within the first 2 years of life. Approximately 50% of all failure
to thrive in this age category is due to maternal neglect.
• accurately document the extent of the clinical findings (physical or
psychological); 2. Intentional drugging or poisoning takes place when parents give the
child a prescribed drug that is harmful and not intended for children.
• provide appropriate treatment of the injuries sustained; and
3. Medical care neglect occurs when a child suffers from a (chronic)
• report the case to the appropriate authorities. disease and the condition worsens due to parental neglect of the
condition. Children are completely dependent on their parents for
Treatment might vary from analgesics to extensive surgical
medical care.
procedures and placement in institutions. Besides medical treatment
for the child, support for the patient and family should be provided. 4. Safety neglect is present when there is a gross lack of supervision,
The majority of parents have normal human feelings (i.e., they are not especially in younger children.
mentally ill), so they might be loaded with guilt. To take an adequate 5. Emotional abuse may occur when the child is repeatedly blamed for
history can be very complicated, as the parents or caregivers are often incidents or rejected by parents and/or caregivers. Severe verbal abuse
in an excited and anxious state. and berating are common. This is a difficult condition to prove.
It might be very difficult to establish whether the injury was
6. Organised abuse is a form of organised crime, and often involves
accidental or nonaccidental. However, the role of the physician is to
multiple victims and perpetrators. The so-called paedophilic and
provide accurate diagnosis and not to play detective. The diagnosis
pornographic rings are the major contributors to this group, but there is
might be very difficult, but the following circumstances should raise
also cult-based abuse, in which the abuse has spiritual or social objectives.
the suspicion of child abuse: