Nurses who regularly see children in their practice are currently treating victims of child abuse, including sexual abuse and neglect, whether they know it or not.
The causes of child abuse and neglect are complex and varied, and occur in all types of families and settings. Nurses must always remain alert to the possibility that abuse may be occurring in any family, regardless of their socioeconomic status.
Nationally, in 1993, averages of 42.9 children per 1,000 were reported to authorities as victims of alleged abuse or neglect. A 1995 Gallop Poll of 1,000 parents yielded the estimate that 3 million U.S. children were victims of physical abuse by their parents, or about 44 per 1,000 children (The future of children, 1998).
Child characteristics may include, the child was prematurely born, the child has disabilities, either mentally or physically, the child exhibits certain behaviors of infancy and childhood, such as persistent crying, the child is chronically ill, and the child has already been victimized. Family characteristics may include, there is other violence in the home, substances, including alcohol, are abused by the parents or caretakers, the parents of caretakers lack necessary maturity, skills or knowledge to care for the child, parental expectations are inconsistent with the childs developmental abilities, the caretaker is socially isolated, the family is experiencing high levels of stress from events such as loss of a job, increased financial burdens, serious illness, death in the family, separation or divorce, adult members of the family have themselves been abused as children (Ohio State Medical Association, 1992).
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Definitions of the major forms of maltreatment are as follows: Physical Abuse- An act of commission by a caregiver that results or is likely to result in physical harm, including death of a child. Examples of physical abuse acts include kicking, biting, shaking, stabbing, or punching of a child. Sexual Abuse- An act of commission, including intrusion or penetration, molestation with genital contact, or other forms of sexual acts in which children are used to provide sexual gratification for the perpetrator. This type of abuse also includes acts such as sexual exploitation and child pornography. Neglect- An act of omission by a parent or caretaker that involves refusal or delay in providing health care, failure to provide basic needs such as food, shelter, clothing, affection, and attention, inadequate supervision or abandonment. Emotional Abuse- An act of commission or omission that includes rejecting, isolating, terrorizing, ignoring, or corrupting a child. Examples are confinement, verbal abuse, withholding sleep, food, or shelter, exposing a child to domestic violence, and other inattentions that result in harm or potential harm to a child (The future of children, 1998).
Under section 2151.421 of the Ohio Revised Code, nurses, as well as many other health professionals, are required to report incidents of suspected abuse or neglect of a child to the Public Children Services Agency, the County Department of Human Services exercising the children services function, or to a municipal or county peace officer. Failure to report can result in a fourth-degree misdemeanor punishable by 30 days in jail or a $250 fine. If found guilty of a fourth-degree misdemeanor, the nurse may lose their nursing license.
The report can be made by telephone or in person, although the requesting agency may request a written report.
The nurse should report any child under 18 years of age, or any physically or mentally handicapped child under 21, who you have the reason to believe has suffered any wound, injury, disability, or condition of such nature as to indicate abuse or neglect. It is important to note that you need only suspect that abuse or neglect is occurring; physical proof or other forms of validation are not required. It is up to the children service agency to further investigate whether abuse or neglect has occurred.
In obtaining data in suspected abuse or neglect, the nurse must conduct a thorough health assessment including a history and physical exam as well as a developmental assessment. The nurse should assess the childs immediate medical needs, obtain the past medical and social history of the child and family members, assess the credibility of the history being provided in light of any pre-existing medical conditions, determine the level of risk to the child if he/she returns home. The following physical findings may be indicative of physical abuse: Bruises and welts, which form regular or symmetrical patterns, will resemble the shape of the article used to inflict the injury. Burns- cigarette, immersions burns, or patterned burns resembling an electrical appliance. Lacerations or abrasions- rope burns, palate, mouth, and external genitalia. Fractures- skull, ribs, or long bones. Abdominal Injuries- Bruises, hematomas, intestinal perforations, ruptured liver or spleen, ruptured blood vessels, kidney or bladder injury, pancreatic injury. Central Nervous System Injuries- Subdural hematoma, retinal hemorrhage, subarachnoid hemorrhage, cerebral infarction secondary to cerebral edema. Other injuries or signs- Munchausen syndrome by proxy, symptoms of suffocation, or chemical abuse.
Findings of neglect may include: Lack of appropriate well-child care, lack of appropriate medical care of chronic illnesses, absence of necessary health aides, such as glasses, absence of appropriate dental care, undernutrition, poor hygiene, developmental delay, untreated medical conditions, and rampant dental caries. Behavioral findings may include: Depression, anxiety, enuresis, excessive masturbation, impaired interpersonal relations, discipline problems, poor school performance, role reversal in which child assumes caretaker role, or excessive household duties including child care (Ohio State Medical Association, 1992).
Because children who are sexually abused are commonly manipulated into secrecy, nurses must remain alert to the possibility of abuse, even when the child says nothing or says that he/she has never been hurt. When the child gives a history of sexual abuse, the information must be received in a sensitive manner and must be taken seriously. An evaluation is mandatory. If the nurse/physician is unable to provide these services, a referral must be made immediately. Time loss can result in danger to the child or lack of evidence in prosecution of the perpetrator (Ohio State Medical Association, 1992).
Behavioral sign and symptoms which may be exhibited in a sexually abused child may include: Extremes of activity, poor self-esteem, poor relationships, express general feelings of shame or guilt, display a distorted self-image, regressive behavior, enuresis, appear frightened of adults, pseudomature behaviors, exhibit a deterioration in academic performance, have an eating disorder, display sexually provocative behavior, sexually abuse a sibling, friend, or younger child, become sexually promiscuous, become pregnant, run away, attempt suicide, specific signs are: rectal or genital pain or bleeding, sexually transmitted diseases in prepubertal children, sexually precocious behavior(Ohio State Medical Association, 1992).
If court evidence becomes necessary, well-documented medical records may eliminate or reduce the time a nurse may be required to spend in judicial proceedings. Medical records provide the most concrete and sometimes only evidence of abuse of a child. The records should be kept in a precise, professional manner and should include: A standard, thorough, pediatric health assessment, direct quotations verbatim, statements made by the child and caretaker, observed behavior, the location of the alleged abusive events, a detailed description of the injuries, results of all pertinent lab and other diagnostic procedures, photographs and imaging studies. For medical records to be admissible in court, the nurse must be prepared to testify: That the records were made during the regular course of business at the time of examination, that the records were made in accordance with routinely followed procedures, and about the care, custody and access of records (Ohio State Medical Association, 1992)
The local reporting agencies for Gallia County include: PCSA Gallia County Courthouse, 740-446-4612 and CDHS/CSEA Third Avenue, 740-446-3222, ext. 11.
Although we have came a long way in acknowledging that child abuse existed and in identification and reporting, nurses certainly have a long way to go in order to become the no-tolerance for child mistreatment advocates that we need to be.
Ohio State Medical Association(1992). Ohio Physicians Child Abuse Prevention Project.
The Future of Children- Protecting children from abuse(1998). R. E. Behrman, M.D.