Child Abuse, Where Are We?

Iyad Al-Aqqad *

Corresponding Author: Iyad Al-Aqqad, Pediatric Resident, Mafraq Hospital, Abu Dhabi, UAE.

Copy Right: © 2023, Iyad Al-Aqqad, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: April 11, 2023

Published Date: May 01, 2023

Case Presentation

2 years old girl presented to ER with Hx of drowsiness since 5 hours.

According to mother ,child woke up at around 10 a.m, the child disappeared for 15 mints then the mother saw her playing with some medicines which are scattered around her on the ground.... 30 mins later the child went in deep sleep... then the mother started thinking that her daughter might ingested some of the medication which she was playing with... they came directly to the hospital. The mother knows only that it is an ? anticonvulsant medication

On Examination:

• Vitals: RR 22/ MIN, HR 115/MIN, BP 95/55 ,SPO2 100% ROOM AIR. CRT < 2 SEC.
• Drowsy but arousable , well perfused, well hydrated.
• Pupils are equal& reactive
• Chest clear
• Systemic examination normal
• Admitted through ER mafraq hospital... to MICU...

The 2 medications are Atomoxetine and Paliperidone

• 4 years later, child presented to ER with Hx of drowsiness and abnormal behavior for 1 day duration.
• She was active playful until the previous day at 6 pm when she went to sleep as usual but didn't wake up until next day morning for school ( usually she wakes up at night for dinner).
• Abnormal behavior was noted in school.
• At home, she was lying in bed, doesn't talk but understands what mother says, has staring look , increased salivation. Had abnormal sudden movement of neck and twitching of mouth for few times.
• Mother was worried as she continued to behave the same so she brought her to ER.
• O/E :
• Vitals: T : 36.6 C , HR112 , RR18, BP110/72, SPO2100 on RA
• General:  delayed responsiveness, drowsy, staring
• GCS 13-14. 
• HENT:  Oral mucosa is moist, Rt. eye nystagmus , both pupils are reactive to light. 
• Neck:  Supple. 
• Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal. 
• Cardiovascular:  Normal rate, Regular rhythm, No murmur. 
• Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds. 
• Lymphatics:  No lymphadenopathy neck, axilla, groin. 
• Musculoskeletal
• Normal range of motion.  
• Neurologic:  Normal sensory, Normal motor function, No focal defects, Normal deep tendon reflexes, negative meningeal sings

More hx :

• There was 4 tablets missing from Risperidone 4mg/ tablet, total of 16mg

Special issues in the family

Seen by the Neuro team and they advised to do CT brain , EEG and to monitor the child closely and observe for Neuroleptic malignant syndrome .

• Brain CT done and was normal
• EEG done and showed :

The background is continuous diffusely slow with an occipital dominant rhythm of about 6 HZ, with intermittent rhythmic delta activity mostly in the right occipital region but also in the left as well as frontal regions as well.

No electrographic seizures or distinct epileptiform activity.

• ECG done was normal

Child started to improve over the next few dayswith no complications .

Social worker was involved and case was reported to police and Social support.

• Child was discharged after that with follow up in the clinic .

Objectives

• Recognize child abuse and neglect
• Identify types of child maltreatment
• How to approach a child with confirmed abuse ?
• To address UAE’s regulations regarding child abuse .

Child Abuse and Neglect

Definition

Child abuse and neglect is defined as an act of or failure to act by a parent , caregiver , or other person defined by state law that results in physical abuse ,neglect, medical neglect, sexual abuse , emotional abuse , or presents an imminent risk of harm to child.

Children exposed to Illegal drug activity

• There is increasing concern about the negative effects on children when parents or other members of their households abuse alcohol or drugs or engage in other illegal drug-related activity
• Many States have responded to this problem by expanding the civil definition of child abuse or neglect to include this concern.

Children exposed to Illegal drug activity (cont.)

• Specific circumstances that are considered child abuse or neglect in some States include:
• Manufacturing a controlled substance in the presence of a child.
• Using a controlled substance that impairs the caregiver’s ability to adequately care for  the child
• Selling, distributing, or giving drugs or alcohol to a child
• Exposing a child to the criminal sale or distribution of drugs.
• https://www.childwelfare.gov/pubPDFs/drugexposed.pdf

Drugging kids for parents' relief called abusive

• The research, published in the Journal of Pediatrics, found an average 160 annual cases in which pharmaceutical drugs were maliciously used on children.
• Using information from the National Poison Data System, Yin found that children were most commonly receiving analgesics, stimulants/street drugs, sedatives, hypnotics, antipsychotics and cough or cold medications.
• He found 1,439 cases from 2000 to 2008. Of those, 14 percent resulted in injuries, and 18 children died. More than half of the cases involved at least one sedating drug; 17 of the 18 deaths included sedatives.
• Why? parents looking for a break, amusement or punishment.

Child Abuse and Neglect: Epidemiological

• The youngest children are the most vulnerable to maltreatment.
• More than one-quarter (27.3%) of victims were younger than 3 years.
• The victimization rate was highest for children younger than 1 year (23.1 per 1,000 children in the population of the same age).

How to approach a confirmed child abuse and neglect ?

• TALKING WITH PARENTS — One of the most difficult  tasks in evaluating a child for the possibility of abuse is informing the parents that an investigation is necessary.
• Parental reactions to such news may range from appreciation to hysterical denials or violence. The possibility of a violent reaction may be anxiety-provoking, even for a child abuse expert, and more so for a health-care provider with less experience in this delicate area .
• It is critical to explain to the parents, in an empathetic, supportive, and nonaccusatory manner, the reasons why it is necessary to file a report of suspected child abuse or neglect.
• The physician should emphasize that his or her first concern is for the safety and well-being of the child.
• Parents usually understand the need for the investigation when they are told that it is necessary for the safety of the child and legally required when an injury is inconsistent with the history.
• The parents should also receive information regarding what will happen once the report is filed (eg, a visit from a CPS worker, social worker,and/or the police).

How to approach a confirmed child abuse ?

• In UAE , it is a mandatory by law to report child abuse
• Whether or not the parents have harmed their child, they deserve to know and must be told that a report is being made, an investigation will be conducted, and the reasons why the investigation is necessary.
• In US, most states require certain professionals to report suspected cases of child abuse and neglect.
• These professionals include medical and mental health professionals, educators, child care providers, social service providers, and law enforcement personnel.
• In UAE’s law also necessitate medical professionals to report child abuse if suspected.

Who reported child maltreatment ?

• For 2013, professionals made three-fifths (61.6%) of reports of alleged child abuse and neglect.
• The three largest percentages of report sources were from such professionals as legal and law enforcement personnel (17.5%), medical health professionals (17.5%) and social services personnel (11.0%).
• Nonprofessionals—including friends, neighbors, and relatives—submitted one fifth of reports (18.6%).
• Unclassified sources submitted the remaining one-fifth of reports (19.8%).

Who reported child maltreatment ?

• A prospective observational study of 1683 United States injured children who were seen in a primary care setting found that 76 percent of 140 children with possible physical abuse and 27 percent of 73 children with likely or highly likely physical abuse were not reported to child protective services (CPS) by their physcians.
• In a follow-up study of these findings, those providers who did not report suspicious injuries to CPS described alternative management strategies designed to monitor for or limit future abuse, and some felt that they could intervene more effectively than CPS.

How to approach a confirmed child abuse ?

• In the reporting of child abuse and neglect, the duty to report supersedes client-professional confidentiality.
• Most states provide immunity from legal liability for reporters in good faith.
• This applies also to UAE’s laws .
• Reporting Barriers :
• Inadequate training to recognize clinical manifestations of child abuse,
• Cultural attitudes,
• Perception that CPS intervention is ineffective,
• and lack of support from professional societies

Reporting process :

• Reports of child maltreatment are made orally by telephone or in person and then followed by a written report to the CPS.
• MOI hotline for child abuse : 116111
• Dubai CPS hotline : 800988
• Sharjah Child hotline : 800700

The written report :

• The purpose of the physician's written report is to communicate with protective custody workers and court officials the nature of the child's medical condition or injuries (eg, failure to thrive, poisoning, burn, fracture), why abuse or neglect is suspected as the cause of the condition, and the strength of the suspicion.
• Information about the setting of the alleged abuse if it occurred in an out-of-home setting such as a school or day-care facility (eg, hours of operation, number of other children in the facility, names of others in the facility who may have information about the alleged abuse)
• The history of the child's injury or condition, as provided by the parent, guardian, or accompanying adult, including any discrepancies between histories provided to different health-care professionals.
• If differing histories have been provided, the different versions should be documented, including information regarding who provided which version, and to whom; the family's words, in quotes, should be used as much as possible, with appropriate attribution.

• The physical examination findings, including a detailed description of the child's injuries, in clear language that is understandable to an individual without medical training. The nature and possible causes of each injury should be discussed individually .
• A sketch of the child's injuries, including skin lesions, but also including fractures, intracranial bleeding, and other injuries not visible on photographs.
• The reasons why abuse is or is not suspected (eg, "the four-month-old child cannot climb out of his crib.")

In addition to the information included in the written report , documentation in the medical record should include :

• History of previous injuries or accidents
• Developmental history
• Procedures performed (eg, skeletal survey, dilated funduscopic examination)
• Diagnosis (eg, suspected child abuse, probable child abuse), followed by a descriptive summary of findings (eg, multiple bruises of various ages)
• Whether a child abuse/neglect report was made
• The final disposition of the child

Child Protection Services

Child Protection Dimensions

1. Child Abuse investigation
2. Prevention of Neglect, Physical, Emotional & Sexual Abuse and Exploitation
3. Child Protection on Roads and in Transport
4. Child Protection in Buildings
5. Child Protection in Crisis and Disasters
6. Child Protection in Public Venues
7. Child Protection from Technological Risks & Threats
8. Protection Against Known Dangerous Persons
9. Child Protection in Schools and Education
10. Child Protection Against Bullying and Peer Abuse
11. Child Protection in Troubled Families
12. Child Protection in Sport

Protection from Human Trafficking

Professionals

If you have concerns of abuse, it is your duty to report by law and for the sake of the child .
Turning Point !!

Child Protection Law in UAE

• Still to be finialized by the Fedrational National Council.
• Changed from Wadeem’s Law to Child Rights Law
• From the official newspapers reports :

• Contains 77 article
• The law would apply to all children up to 18 years, regardless of nationality and religion.
• The draft law provides for children’s right to security, to freedom from inhuman, cruel, or degrading treatment and the right to special protection during childhood. It also states a child’s right to life, the right to a name, the right to express their views freely, the right to health care, the right to protection from economic and sexual exploitation, and the right to education.
• The bill allows childcare specialists to remove children from their homes against parents’ wishes and without judicial permission in cases of imminent danger.
• After the child is removed from the home, the childcare specialist must obtain permission from the court within 24 hours
• In less severe cases, specialists may intervene by visiting regularly, providing social services and mediating a solution between the family and the child.
• If the family refuses the solution or does not respond within 14 days, the case will then be referred to higher authorities.
• Those who obstruct the work of a childcare specialist are subject to a fine between Dh5,000 and Dh50,000.
• In another major move for the country, the draft also prohibits child-sex offenders from working with children.
• Any offender who finishes a prison sentence would be prohibited from living within five square kilometres of the victim’s home.
• In all cases, offenders will not be released from prison until they go through psychological tests to ensure they are not a threat to society.
• Among other rights, children are entitled to health care, education, a safe environment, paid expenses and the right to know both parents and keep close relations with them.
• Before parents are given custody of a child, they will have to prove themselves of sound mind.
• Members were also keen to impose harsher punishment on offenders.
• Those who put children in danger, abandon them, neglect them, leave them without supervision, do not enrol them in school or register them upon their birth, are subject to a prison sentence or a fine of no less than Dh5,000.