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Case studies of child abuse and neglect

Child abuse and neglect is defined in different ways in various cultures.

In general, any commission or omission of acts case studies of child abuse and neglect adult caretakers that imposes a negative impact on physical, psychological, and social wellbeing of a child is considered child abuse and neglect 2,3.

Child abuse has existed throughout the history of mankind, but studies in this field have emerged since the last century. For the first time in 1962, a pediatrician, Henry Kempe, set forth a diagnostic category and coined the term "Battered Child Syndrome". After a 12 year contentious period, all 50 states in the USA passed child protection laws for the prevention of child abuse and neglect 1,4.

Child abuse and neglect may take many forms from inflicted injuries to failure to thrive due to inadequate feeding, from sexual abuse to emotional abuse, all of which limit the child's physical and mental development 2,3.

Economic, social, environmental, and cultural risk factors including poverty, low educational level, unemployment, violence, and substance abuse may lead to child abuse and neglect. Intra-familial risk factors include parental physical or mental health problems, certain characteristics of the child, parent deprivation, and unrealistic expectations of the family about the child's capabilities 5. Child abuse and neglect was recognised in developed countries during the latter part of the last century and prevention programs were established 2,4.

Developing countries have joined the western countries in recognising this issue as a socio-medico-legal public health problem within the last couple of decades 6-8.

In Turkey, Turkish Society for the Prevention of Child Abuse and Neglect has led the way to increased professional awareness of this important entity.

The medical field, however, has not been involved in these efforts to a desirable extent, until 1990s. As the medical field began to get more involved in the recognition of child abuse and neglect, physicians have started publishing on child abuse and neglect, as well 6.

In this paper, we present five cases diagnosed with child abuse and neglect, two of which had a fatal course. We hope these cases will guide physicians in Turkey and in other developing countries to be more diligent about the signs of child abuse and neglect. Case Reports Case 1 Two and a half year-old male, youngest child of a family with four children was brought to the emergency room of a University Medical School Hospital because of bleeding from the right ear and projectile vomiting after falling from a top bunk bed.

Physical examination revealed no abnormalities except for bleeding from the right ear. He was observed for 24 hours after his vital signs were stabilised and was discharged to his parents with a diagnosis of head injury.

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Six days later, he returned to the same hospital complaining of right facial asymmetry while talking. Physical examination revealed superior posterior tympanic hematoma in the right ear.

  • Two of these cases had a fatal outcome, one had residual neurological handicaps, and two were lost to follow up;
  • Ironically there was no conviction in the two fatal cases;
  • The police arrived, removed the Jason from the mother, and returned him to the foster home;
  • These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings;
  • These teams initiated collaborations with community agencies such as Child Protection Services, prosecutors, law enforcement officers, and school staff attempting to establish regional organization of child protection services 14;
  • On admission, physical examination revealed confusion, bilateral peri-orbital red fresh bruise, 2 x 3 cm size blue-purple old bruise on his cheeks bilaterally, 1 x 2 cm size red, new bruise on his forehead, edematous swelling of his upper lip, 2.

Computerised tomography CT of the head verified the tympanic hematoma and revealed right temporal linear fracture. Treatment for right peripheral facial paralysis was prescribed and he was again discharged to his parents.

Four months later, he returned to the hospital for a third visit because of falling from a balcony, a distance of 3-4 meters. Physical examination revealed, left peri-orbital edema and red fresh bruising, superficial abrasions over the right temple and cheek, and deformity and pain on palpation of the left forearm, all of which indicated acute trauma.

X-ray of the left forearm revealed acute spiral fracture of the ulna and the radius. His abrasions were dressed, and his forearm was cast in the emergency room. Since the attending physician suspected inflicted trauma, hospitalisation was suggested.

The father refused hospitalisation and discharged his son against medical advice, which prompted a forensic report case studies of child abuse and neglect the police department. The father was tried for abusing his son and sentenced to one year, six months of jail time. There was no report filed with the Child Protective Services. There was no recommendation to assess the other children in the family, either. No expert witness was invited to trial. Case 2 Six year-old girl, the second of four children in her family, was brought to the University Medical School Hospital by her stepmother with loss of consciousness and a story of falling from a sofa.

Physical examination revealed absence of pupillary light reflex with fixed, dilated pupils, and absence of breathing and pulse. She was intubated but did not respond to cardiopulmonary resuscitation. She was pronounced dead after thirty minutes of resuscitation. Postmortem examination of the child was performed one day after death, which revealed numerous different colored old and new bruising between 0.

In internal examination, there was a widespread red new ecchymosis on the internal surface of her occipital scalp and over the vertex, and a linear occipital fracture. There were also occipital subdural hemorrhage, subarachnoidal hemorrhage at the left temporal lobe, and brain edema. The cross sections of her lungs were edematous, and there was a laceration at the right renal capsule.

  • Shortly before the court hearing in which the mother expected Jason to be returned to her custody, the case manager and agency worker informed the mother that they would be recommending continued placement with extended visits which were more carefully monitored "to help the mother understand the importance of administering medication properly;
  • The police arrived, removed the Jason from the mother, and returned him to the foster home;
  • These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions;
  • Internal examination revealed multiple ecchymotic lesions of different colors under the scalp, a sutured fronto-temporal wound, and 0.

The cause of death was brain damage due to blunt head trauma. The eyes were not removed for retinal examination. Forensic report was filed with the police department. At the end of the forensic investigation, her stepmother confessed that she slammed the child against a wall because of bedwetting. After the stepmother hit the child's head against the wall, she also kicked her until the child became unconscious. To resuscitate her, stepmother took her to the bathroom, shook her by the shoulders and wetted her head by the use of a hose.

The girl slipped from her hand and hit her head against the wall again, which started wheezy breathing but she did not gain consciousness. The stepmother was convicted with involuntary manslaughter in Criminal Court.

  • Following this incident the agency worker wrote a report which listed her concerns about the other children in the home;
  • Other risk factors including isolated living conditions, teenage parenthood, low educational status, and parental substance abuse should also be considered in assessing suspect abuse cases 23,24;
  • Clinical samples may not be representative of all cases of child maltreatment;
  • The visiting proceeded as ordered and 3 months later the case manager recommended return.

On appeal, seven months later, she was acquitted. There was no report filed with Child Protective Services.

None of the other siblings was assessed for possible abuse. Case 3 Three month-old male infant, the only child of his family, was referred to the University Medical School Hospital from a local hospital. On admission, physical examination revealed confusion, bilateral peri-orbital red fresh bruise, 2 x 3 cm size blue-purple old bruise on his cheeks bilaterally, 1 x 2 cm size red, new bruise on his forehead, edematous swelling of his upper lip, 2. The latter two lesions appeared to be healing burn lesions.

At the university hospital, head CT revealed subarachnoid hemorrhage. One day later, repeat head CT revealed bilateral fronto-temporo-parietal subdural hematoma, right occipital subdural hematoma, and right temporal parenchymal hemorrhage.

Abdominal CT revealed linear laceration of the spleen and minimal perisplenic fluid accumulation. Full skeletal survey and eye examination were not done.

In two days, his respiratory status deteriorated and he was intubated. His mother reported his father beat the child up.

Neglect / Chronic Neglect Case Study

After his treatment in the intensive care unit was completed, he was discharged to his mother. The child was neurologically stable on discharge. Forensic report was filed with law enforcement. His father was arrested. His mother testified in court that his father physically abused the child on many occasions causing umbilical hemorrhage from a beating at two weeks of age, left subcostal and periorbital ecchymosis from a beating at two months of age, and inflicted burns by pressing his feet against a hot stove at 2.

She denied any medical visits for any of these inflicted injuries. The father was convicted with intentional child endangerment and sentenced to two years, two months, and twenty days of jail time. Case 4 A four year-old female child of a single mother with no other children who works as a prostitute was brought to the emergency room of a University Medical School Hospital five hours after she fell from a chair.

She was immediately intubated. Head CT revealed 1. She was taken to the operating room for evacuation of the hematoma pressing on the right hemisphere. During the operation she had cardio-respiratory arrest. Despite extensive resuscitation, she was unresponsive and was pronounced dead. Postmortem examination and autopsy were performed within 24 hours.

External examination revealed 10 x 10 cm red fresh bruise on the left side of her upper abdomen, four blue-purple old bruising of 1 to 1. Internal examination revealed multiple ecchymotic lesions of different colors under the scalp, a sutured fronto-temporal wound, and 0.

Cerebral and cerebellar examination revealed acute edema, subdural hematoma, and enlargement of the third ventricle. Abdominal examination revealed petechial bleeding on the anterior surface of the liver and a hematoma of 5x8 cm on the left side of omentum major. Due to suspect physical abuse, a forensic report was filed with the law enforcement.

The mother was tried for negligence after which she was acquitted. No expert witness was called to trial. Case 5 Four year-old male child of a family with three children was brought to the University Medical School Hospital by his father complaining of vomiting after he woke up following a fall six hours prior to coming to the hospital.

His mother and father provided a different fall history. His father reported the child fell down while walking but his mother reported he fell from a sofa. The assessment at the emergency room revealed a child in coma with Glascow coma scale of four, irregular breathing, left midriatic pupil 4 mmleft deviation of the eyes, and hemiparesis on the right side.

The cranial CT revealed case studies of child abuse and neglect. He was taken to the operating room.

Child Abuse and Neglect

Epidural hematoma was drained via left temporal craniectomy. Skeletal survey and retinal examination were not done. Inconsistent history of trauma prompted a forensic report to law enforcement. On discharge to his parents, he had residual right upper extremity paresis and limited medial vision on his left eye.

His father was tried criminally for physically abusing his son. Criminal investigation revealed that he got annoyed with being interrupted by the child playing near him while he was praying.

He pushed the child toward the wall. The child lost his consciousness subsequent to impact from the wall. After the father was tried for involuntary child endangerment, he was acquitted. There was no report filed with Child Protective Services, nor was there an abuse assessment of the other children of the family. Two of these cases had a fatal outcome, one had residual neurological handicaps, and two were lost to follow up.

Thus, it is appropriate to think that this series consists of most severely and overtly abused cases and represents the tip of the iceberg of physically abused children in the region.