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
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:
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
