When asked to describe their most difficult cases, many nurses put child-abuse cases at the top of their list. Most of us can deal (intellectually, at least) with the ravages of cancer or the deterioration that comes with aging. Child maltreatment can be much harder to cope with emotionally.
As much as we may wish for a world without child abuse, we still continue to see its ugly marks nearly every day. As a nurse, you play a key role in handling child abuse cases, both in your professional role and as a member of the community. The greater your insight into the clinical and legal aspects of child maltreatment, the greater your ability to meet the challenges these difficult cases can pose.
The term child abuse encompasses a broad spectrum of maltreatment, including physical abuse, sexual abuse, and neglect. Understanding the three general clinical concepts below will help you care for abused children more effectively.
Concept #1: Bruises on babies are nearly always bad.
Everyone understands that children get bruises. But as pediatric and forensic nurses know, an unexplained bruise in a nonambulatory child isn’t the same as an unexplained bruise in a 2-year old. Nonambulatory infants (those who can’t move on their own) get bruises only from external sources.
Although accidents do happen, the parent or other caregiver should be able to reasonably explain any bruise on an infant’s body. A child with an unexplained bruise deserves a full child-abuse workup. If you see bruising in a nonambulatory child, be suspicious and refer the child for further workup. Coagulation studies and a skeletal survey can yield more information.
Be aware that for an infant with normal blood clotting, the usual activities of daily living shouldn’t cause a bruise. So if the infant you’re examining doesn’t have a clotting disorder and the injury isn’t consistent with the parent’s explanation, consider the possibility of an inflicted injury (unless an accident can be identified). Bruises on the soft tissue of the body, ears, neck, and trunk should raise the greatest suspicion of child abuse. If you note a bruise, the child must undergo a complete skin exam to check for other injuries.
Every infant with a bruise needs a careful assessment, which should include skeletal imaging (a bone scan or skeletal survey) and coagulation studies. In many cases, the workup also includes a computed tomography (CT) scan and a retinal examination—screening tools that may reveal more evidence of abuse. For example, if you find bruising on the abdomen, the infant should have a CT scan to explore for an intra-abdominal injury.
Commonly, though, radiologic and blood tests show normal results, revealing no specific mechanism for the child’s condition. When this occurs, you play a key role in deciding how an abuse investigation should proceed while continuing to rule out the possibility of a medical condition. A child abuse specialist should always be part of the multidisciplinary team of physicians, nurse practitioners, social workers, radiologists, and child protective services staff that investigates every suspected child abuse case.
Keep in mind that normal findings for the skeletal survey and other studies don’t necessarily rule out abuse. A decision on how the case should proceed should be made by an experienced interdisciplinary team of care providers.
Concept #2: Consider a possible head injury in an infant with vomiting, irritability, and lethargy.
Over the past few years, we’ve learned that inflicted traumatic brain injury in infants is a diverse spectrum, of which “shaken baby syndrome” is just one aspect. Infants are sensitive to forces applied to the head. The most dramatic and severe injuries are easiest to identify; for instance, after a blow from a hammer, an infant who was smiling and happy one moment may be comatose the next.
But an infant with an insidious onset of such symptoms as vomiting, irritability, and lethargy poses a much greater challenge. In young infants, these findings can have many possible causes—but inflicted head injury is high on the list. In many cases, a vomiting, irritable infant is misdiagnosed with the flu or gastroenteritis when in fact she has a head injury. Several studies, including my own, show that healthcare personnel may miss head injury in infants. For example, up to one-third of infants diagnosed as having been shaken show some evidence of a previous head injury; vomiting could represent onset of a head injury that has gone undetected. These are important facts to consider when evaluating an infant for a possible head injury.
A full workup for an infant with a suspected inflicted traumatic brain injury includes CT and magnetic resonance imaging (MRI) scans of the head, a skeletal survey, appropriate blood work, and a retinal exam by an ophthalmologist.
Concept #3: Most prepubertal children who’ve been molested have normal exam findings.
Any child who discloses a history of sexual abuse should undergo a medical exam. The purpose of the exam isn’t just to reveal medical findings; it’s also to reassure the victim and her family that she’s normal and not “damaged for life.”
About 85% to 95% of prepubescent children who disclose sexual abuse have normal exam findings. Yet normal findings don’t rule out sexual abuse, because many types of sexual abuse (such as fondling and oral sex) don’t cause physical findings. Also, many children don’t disclose sexual abuse until days to weeks after it has occurred, giving the injuries time to heal. Even significant trauma can heal in a few days without scars.
Thus, if a police officer or protective worker asks you after you’ve completed an exam on a child, “Has she been molested?” your response should be, “We don’t know yet.” That’s because to answer this question, you need to know the history of the case and what, if anything, the child has disclosed. It’s all about the history. A good forensic interview and complete investigation must be done.
Cultures for sexually transmitted diseases (STDs) commonly are taken during the exam. Although most children with STDs have symptoms, this isn’t always the case, so it’s best to obtain cultures on any child who discloses sexual abuse.
Approach to the clinical examination
The clinical exam is a crucial part of the healing process; when done appropriately, it’s rarely traumatic for the child. “Done appropriately” means done by experienced personnel who specialize in this type of examination—preferably at an advocacy center or other center specializing in child sexual abuse. (See the inset below.)
Specialized child-abuse advocacy center
Specialized child-abuse advocacy centers provide a safe haven for the child to be interviewed and examined by a multidisciplinary team of experts. These centers bring together professionals equipped to help the abused child through this traumatic time. Such an environment helps ensure privacy, reduces the risk of undue trauma to the victim, and provides the highest level of expertise.
Child-abuse advocacy centers typically use a multidisciplinary team consisting of a forensic nurse, a nurse practitioner, a physician who is an expert in child abuse, a social worker, intake coordinators, on-call legal aid, and a director. They also have a connection to a women’s shelter. In addition, police officers are available; an assigned officer is best. Personnel are trained in interacting with trauma victims during both the acute and chronic phases. The exam room is nonthreatening. A separate room with a warm, homelike environment is used for interviewing the child.
Of course, a child with acute injuries and bleeding must be cared for right away at the closest medical facility. In prepubescent children, though, acute injuries from sexual abuse are rare. More commonly, the victim discloses he or she was molested at some time in the past.