child abuse and maltreatment
TRANSCRIPT
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Child abuse and maltreatment
Dr Samaneh Farnia
Child and adolescent psychiatrist
Mazandaran Univrsity of Medical Sciences
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• The best available data suggest that approximately 30% of child and adolescent psychiatric outpatients , and as many as 55% of child and adolescent psychiatric inpatients have a lifetime history of abuse or neglect
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A history of abuse is a highly significant risk factor for the development of
• Psychiatric disorders, Affective dysregulation, aggressive behavior, insecure attachment, academic under-achievement
• Medical health problems
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Child abuse
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; or an act or failure to act, which presents an imminent risk of serious harm.
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four major types of maltreatment:
• Physical abuse,
• sexual abuse,
• psychological maltreatment,
• neglect
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CDC reports:
• Emotional abuse 12%
• Physical abuse 9%
• Neglect 3%
• Sexual abuse 1% ( 10 -25 % of girls)
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آمار اورژانس اجتماعی
هشت درصد از مداخلات : کشوراورژانس اجتماعی رئیس کهاورژانس اجتماعی مربوط به کودک آزاری است
،کودک آزاری مربوط به غفلت و بی توجهیدرصد آن 50•
درصد از نوع آزار عاطفی و روانی، 30•
وآزار جسمی درصد 16تا 15•
جنسی استآزار درصد 4تا 3•
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آمار اورژانس اجتماعی
پدر، درصد کودک آزاری توسط 57•
مادر، درصد از سوی 26•
درصد از سوی خواهر و برادر و 1.3•
درصد توسط نامادری و ناپدری و 9تا 8•
غریبهدرصد از سوی افراد 1.5•
.انجام شده است
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Homicide
• During 1st week : exclusively by mothers
• 1st week to 13 y : mothers = fathers
• 13 y to 15 y : fathers 63%
• 16 y to 19 y : fathers 80%
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Risk factors
• Parental mental illness or substance abuse
• Lack of social support
• Poverty
• Minority ethnicity
• 4 or more children in a family
• Young parental age
• Parental hx of abuse
• Stressful events and violence
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Risk factors
• The most common age of initial sexual abuse is 8-11 y.
• Sexual abuse in all SES
• Known perpetrators more common than extra-familial source
• Physical abuse and neglect in lower SES
• Child: prematurity, ID, physical handicaps
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Clinical presentation
Caregiver• Lack of reasonable explanation for the injury• Excessive or inadequate level of concern• Delay in seeking medical attentionChild • Unusually fearful and distrustful• Afraid to go home• Sleep difficulties• Substance abuse• Hypersexual behavior
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Medical finding
• Cutaneous injuries, bruises, lacerations in the shape of an object or in special areas e.g. upper arms, medial thighs
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Medical finding
• Head injuries , ICH, retinal hemorrhage, bilateral ocular injury, traumatic hair loss with scalp hematoma
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Medical finding
• Stocking –glove distribution burns, perineum burn, multiple burn in various stage of healing, recognizable shape
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Medical finding
• Skeletal injuries, posterior rib fx, multiple fx in various stage of healing, metaphyseal fx in long bones of infants, spiral fx, subperiostealhemorrhage, epiphyseal separation,…
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Medical finding
• Ear injuries, twisting injuries of the lobe,…
• Abdominal injuries, hepatic hematoma, laceration, …
• Chest injuries, pulmonary contusion’ pneumothorax, pleural effusion
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Medical finding of sexual abuse
• Vague somatic complaints (abd. pain, headaches)
• Secondary enuresis and encopresis
• Redness or irritation, laceration, scarring, bruising of anogenital, anal dilatation
• Repeated UTI and or hematuria
• Anal fissures or blood in the stool
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Intervention
• History taking before P/E
• Use of sedation for collection of forensic samples if the child is unable to cooperate
• Offer reassurance about healing and recovery
• A careful history and comprehensive physical exam
• A minimum number of times, smallest number of clinicians
• Exam should not cause additional emotional trauma
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Intervention
• Radiologic documentation of skeletal injuries (in child less than 2 y but not helpful in children older than 5 y)
• Brain or head injuries (CT scan)
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Impact of abuse
• Timing/ duration/ frequency and specific characteristic of abuse
• Child’s resilience and vulnerability
• Poor outcome : longer duration, use of force, penetration in sexual abuse, perpetrator close or related to child
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Impact of abuse
• Overstimulation of HPA , elevated cortisol level
• Altered brain homeostasis, limbic and hippocampal damagememory deficit and emotion dysregulation
• Dissociative mechanism first protective then maladaptive
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Impact of abuse
• Hyperarousal, vigilance, irritability, aggression, sleep difficulties
• Attachment dysregulation
• Substance abuse and self injurious behavior
• Attentional problems
• Depression and suicide
• Dissociative and psychotic disorders
• Anxiety and PTSD
• Multiple somatic and health problems
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Impact of abuse
Substance use, self medication
• Alcohol serves to reduce anxiety
• Opiates trigger soothing dissociation
• Stimulants activate mesolimbic dopaminergic rewards area in children deprived of true rewards in their lives
- Physical abuse enact, more support, less PTSD
- Sexual abuse secrecy and shamemore PTSD
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Prevention
• Home based models
• School based models
• Identifying high risk groups
• Provide an accepting relationship
• Increase family’s competence
• Decrease social isolation
• Parenting groups
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Child and parent treatment
• Protect the child
• Strengthen the family
• Supportive and problem oriented approaches
• Family based therapy
• TF-CBT
• Play therapy
• Clonidine
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Clonidine (an α-2-agonist) to decrease NE release(0.003-0.010 mg/kg)Initial dose of 0.05 mg of clonidine for patients between 4 and 17 years of age, about half an hour before bedtime and increased by 0.05 mg increments to a maximum of 0.4 mg
Clonidine should be tapered gradually when it is discontinued, even if it is used only at night for insomnia.
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Given that many children and adolescents with PTSD have comorbid depressive and anxiety disorders, SSRIs are recommended in the treatment of these coexisting disorders.
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Initial dose children adolescents
Citalopram 10 20-40 20-40
Escitalopram 5-10 10-20 10-20
Fluoxetine 10 20 20-40
Fluvoxamine 25 50-200 50-200
Sertraline 12.5 - 25 50-200 50-200
Paroxetine 10 10-30 20-40
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References
• Dulcan’s texbook of child and adolescent psychitry , 2016
• Green’s child and adolescent clinical psychopharmacology, 2019
• Kaplan_&_Sadock’s_Comprehensive textbook of psychiatry , 2017, Wolters Kluwer.