Let's talk about the risk factors for child maltreatment, and then specific risk factors for abusive head trauma. My name is Gail Horner. I'm a forensic nursing specialist with the International Association of Forensic Nurses. I joined IFN staff a year ago. Prior to joining IFN, I worked at a hospital-based child advocacy center at Nationwide Children's Hospital in Columbus, Ohio as a pediatric nurse practitioner in the child abuse program. I saw children in an assessment clinic for concerns of a multidisciplinary team assessment clinic for concerns of sexual abuse, physical abuse, and human trafficking. I also performed consults on children with physical abuse injuries that were severe enough to require hospitalization and coordinated a team of sexual assault nurse examiners in our emergency department. Then my daughter had a baby and I retired and moved to Denver, Colorado. Anyway, we will discuss risk factors related to child maltreatment and abusive head trauma. The planners, presenters, and contact reviewers of this course have no conflicts of interest. To receive continuing nursing education contact hours, you will need to attend the course in its entirety and then complete a course evaluation. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation. For the next half hour or so, we will discuss risk factors for child maltreatment, especially physical abuse, and then discuss specific risk factors associated with abusive head trauma. Let's take a look at the epidemiology of child maltreatment. These statistics are according to the US Department of Health and Human Services Child Maltreatment Report of 2020. This report, if you Google Child Maltreatment 2020, is a very comprehensive report of Child Protective Services investigations regarding child maltreatment in 2020. But look at the three categories, CPS investigations, child victims, and child deaths. You see a pretty significant decrease from 2019 to 2020. What do you think? Is this decrease likely reflective of the social isolation that children experienced in 2020 due to COVID? Certainly, the decreases could be related to children being home more isolated with primary caregivers. They were not around extended family and friends, and not attending school, and other functions. They did not have the opportunity to disclose abuse, and non-abusing adults did not have the opportunity to see them, and to know any injuries or changes in the behavior that might make them concerned about possible child maltreatment, and then not be able to report the concerns to Child Protective Services. Just something to keep in mind when looking at these numbers. Note the number of Child Protective Services investigations in 2020. Over three million. These indicate reports that were made to Child Protective Services that CPS deemed warranted an investigation. Then look at the number of child victims. This number, 618,000 in 2020, indicates children for which CPS received a report, CPS investigated that report, and they were able to substantiate the child as being a victim of some form of child maltreatment. Then certainly look at the deaths. Over 1,700 children died as a result of child maltreatment in 2020. These represent the children for which CPS received a report, they investigated, they substantiated them as a victim of child maltreatment and identified their death as occurring as a result of some form of child maltreatment. But if you look at all of these numbers, they're really just the tip of the iceberg when considering the children that experience child maltreatment. The majority of child maltreatment is never reported to Child Protective Services. Let's look at the different types of child maltreatment. In 2020, over three-fourths of children suffered neglect, 16.5 percent physical abuse, 9.4 percent sexual abuse, and 0.2 percent sex trafficking. These numbers are pretty consistent. The breakdown of child maltreatment is very consistent that the vast majority of victims of child maltreatment experienced neglect, followed by physical abuse and sexual abuse. When considering fatalities related to child maltreatment, it's important to note and to understand that the majority of children who die as a result of child maltreatment die as a result of neglect alone or in combination with other forms of child maltreatment. Nearly three-fourths of the children who died in 2020 as a result of child maltreatment. Died from neglect. Nearly half, 43 percent died as a result of physical abuse alone or physical abuse in combination with other forms of child maltreatment. Abusive head trauma is by far the most common cause of death due to physical abuse. If you look, younger children are much more vulnerable for to die as a result of child maltreatment, both neglect and physical abuse, with 68 percent of the children being less than three years of age, and nearly half, 46 percent less than one year of age. In 2020, 725 children died in America related to physical abuse. Let's take a look at familial psychosocial risk factors and protective factors for child maltreatment. It's very important for the forensic nurse to assess for psychosocial risk factors and strengths. It's also important to understand that a report of suspected child maltreatment is never made based solely upon risk factors present in the family. Let's look at risk factors. Caregiver mental health concerns, caregiver substance abuse, and domestic violence in the home. Caregiver history of maltreatment in childhood may increase the risk for their child to then be abused in some way. But also, I think it's important for the forensic nurse to realize that caregiver history of maltreatment in childhood can contribute to caregiver mental health concerns, caregiver substance abuse, and domestic violence in the home. It's important to link the caregivers with a history of maltreatment, with resources to begin to heal from their own trauma. We also need to assess for previous or current familiar involvement with child protective services or law enforcement. Financial stressors such as food insecurity or homelessness. Teen parents are also at increased risk to have children who experienced child maltreatment. But we also need to assess for protective factors such as social supports. Maybe that teen parent has a mother or a father or some other relative or older friend who is very supportive and helps them take care of that child. Assess for the parent's self-efficacy, their sense of competency in parenting, and their love of their child. Those are all protective factors. It's important to realize that corporal punishment use is indeed a risk factor for a child experiencing physical abuse. Decades of research have taught us some things about the use of corporal punishment. First of all, it really just doesn't work. It may result in immediate compliance, but long-term, it's an ineffective form of punishment. Children do not internalize the morals and values that parents are wanting to teach, and therefore, there is no long-term change in behavior. Corporal punishment use can lead to lower or slower cognitive development, poor long-term mental health outcomes, and a negative effect on parent-child relationship. Across decades, across studies, the number one risk of the use of corporal punishment is that these children are at increased risk to experience physical abuse at the hand of their caregiver. In my personal practice as a child abuse pediatric nurse practitioner, I would say the majority of children that I saw due to a concern of physical abuse, it was a frustrated parent, stressed out, coupled that with unrealistic developmental expectations of the child's behavior and the use of corporal punishment, increases risk for children to be physically abused at the hand of a caregiver. According to the US Department of Health and Human Services, the top three familial psychosocial risk factors present in children who were substantiated to be victims of child maltreatment in 2020 were domestic violence, drug abuse, and public assistance. Computer is being a little wacky. Let's look at child risk factors. There are certain factors about children that place them at increased risk for experiencing physical abuse and other forms of child maltreatment. Premature babies are at increased risk due to the fact the bonding is oftentimes altered. They're hospitalized for days, weeks, or months. Then once they come home, they may have accompanying medical problems or developmental issues that can drain the issue, the resources of time and money of the family, placing them at increased risk. A colic, fussy baby, a crying baby is at increased risk. Crying is the number one risk factor for abusive head trauma. Children with developmental delay or physical disabilities are at increased risk. First of all, these children may not be meeting up to parental expectations of what it was going to be like to be a parent and to have a child. They may have accompanying, their delays may drain the resources of time and money of the family, placing them at increased risk. Children with behavioral concerns are at increased risk for child maltreatment due to their behaviors. Children with chronic illnesses, again, this is an added stress on the family, may drain the resources of time and money. And this is not the idea of parenting that this parent had in mind. And so they are at increased risk for experiencing physical abuse and other forms of child maltreatment. Multiple gestations, those children are at increased risk simply because there's more than one of them to take care of at the same time. And unwanted children are also at increased risk to experience child maltreatment. Now let's focus on abusive head trauma, the deadliest and most debilitating form of child physical abuse with a mortality rate of 20 to 25%. Let's look at the epidemiology of abusive head trauma. Estimates show that in children aged five years and younger, abusive head trauma occurs in about 20 to 30 per 100,000 infants per year. However, the true incidence of abusive head trauma is thought to be even higher. The peak incidence of abusive head trauma is between ages four to six months. It is thought that between 18 to 25% of children diagnosed with abusive head trauma die, and up to 80% of survivors will live with significant lifelong physical, developmental, and emotional sequelae. Certain anatomical differences in infants increase vulnerability to abusive head trauma. First of all, the head size. In proportion to the rest of the body, the infant head is larger, which means children land head first when they fall. And let's talk about the developing brain. We know that the brain is not completely developed until about age 25, that there's myelination and refinement of the neuro pathways that occur over decades. And also when we think about the infant brain and the young child brain, consider this, the brain triples in size between birth and age five. So there's a lot of changes going on in the brain in the first five years of life. A child's brain has a higher water content than adults. So the brain is more likely to suffer acceleration, deceleration injuries. The head and neck are unstable, depending more on support from ligamentous structures than fully developed bony structures. The unmyelinated brain in an infant is more likely to experience shearing injuries. The skull is not fully developed and easily deformed. In trauma, it may compress brain tissue when impacted, causing coup rather than contra coup injuries more commonly seen in adults. Infants and young children are also at increased risk for abusive head trauma due to their behavior. Infants and young children are very dependent upon caregivers and require a lot of caregiver time and attention, trying which peaks at about six to eight weeks and then declines is probably the single greatest risk factor for abusive head trauma. The caregiver becomes angry and frustrated over the crying and screaming. Oftentimes feeding the baby, changing the diaper or holding them or giving them a pacifier does not soothe the baby. The baby just won't stop crying. Caregiver frustration rises and the result is abusive head trauma. Triggering events can be feeding problems, toilet training, medical problems such as colic. Let's take a look at a couple of recent studies exploring abusive head trauma risk factors. Eisman and company in 2022 conducted an exploratory study to describe the household competition composition of children diagnosed with abusive head trauma. And also they assess the relationships between patient and household characteristics, perpetration and fatality. They looked at 10 years of patients diagnosed by child abuse pediatricians with abusive head trauma at a pediatric hospital. Their sample size was 200 patients. Children ranged in age from birth to seven years with a median age of six months. More than half of the children, 59% were less than six months of age. The mortality rate was 13%. When describing possible perpetrators, 65% were male. The most frequent possible perpetrators were biological fathers, boyfriend of the mother or guardian and biological mothers. Patients who had siblings living with them in the home had greater odds of the possible perpetrator being their biological parent, especially if they had a sibling under five years of age living with them. Only children had greater odds of the alleged perpetrator being a boyfriend or girlfriend of their parent or guardian. Patients less than 12 months of age had greater odds of the perpetrator being a biological parent, while patients 12 months of age or older had greater odds of the possible perpetrator being a boyfriend or girlfriend of their parent or guardian. The mortality rate from abusive head trauma was higher among patients who were 12 months of age or older the mortality rate was also higher when the possible perpetrator was a boyfriend or girlfriend of their parent or guardian. The mortality rate did not differ significantly based on patient sex, race, ethnicity, number of siblings or number of adults living in the home. Nortricia and Company in 2021 conducted a retrospective analysis of the forensic evaluations of 783 children who were equal to or less than the age of five who presented with head trauma. 31.5% were determined to be abusive head trauma, 44.2% accidental trauma and 23.8% of the children who presented with head trauma the cause of the head trauma was undetermined. Certain risk factors for abusive head trauma were identified looking at the age of fatal abusive head trauma. These children were older with a median age of 23 months when compared to those with non-fatal abusive head trauma with a median age of seven months. Certain familial psychosocial factors were associated with abusive head trauma, intimate partner violence, substance abuse, prior involvement with law enforcement and an unknown number of adults living in the home. There were also presenting symptoms that were associated with abusive head trauma, lethargy, unresponsiveness, loss of consciousness and seizures and then injuries associated with abusive head trauma, bruising and multiple fractures. An isolated skull fracture reduced the risk of abusive head trauma. No history given for the injury was associated with abusive head trauma. When talking about risk factors for abusive head trauma, we cannot, we just cannot fail to talk about sentinel injuries. Up to 31% of infants and children who suffer abusive head trauma have experienced a previous sentinel injury, a physical abuse injury that went unrecognized as resulting from abuse and was not reported to Child Protective Services and the child did not receive a physical abuse workup. The most common sentinel injury is bruising. Then fractures, intraoral injury and subconjunctival hemorrhage. Any of these injuries, especially in a non-ambulatory child without a clear history of injury should stimulate concerns of physical abuse and a physical abuse workup is indicated. Many of the sentinel injury studies were in many of the sentinel injury studies, the injuries were documented by medical providers but they failed to recognize the injury as possibly concerning for physical abuse and therefore the injury was not reported to Child Protective Services and a physical abuse workup did not occur. Forensic nurses provide care to pediatric victims of trauma. Understanding risk factors for both child maltreatment in general and abusive head trauma specifically can assist the forensic nurse in recognizing abusive head trauma and intervening appropriately. In this module, we discussed risk factors for abusive head trauma. Now we will work through an interactive case study. Take a look at the references. The next two slides are a list of references used for this presentation. If you have any questions, please email me. My email is ghorner at ifn.org and I'll spell the Horner. So it's G-H-O-R-N-O-R at I-F-N.org. Again, let me know if you have any questions.

forensic nursing

child maltreatment

abusive head trauma

caregiver mental health

domestic violence

developmental delays