1 Programa Básico sobre Abuso InfantilPara profesionales de la salud

2 Desarrollado por la fuerza de trabajo de Programas Médicos de ISPCANMiembros: Dr. Steve Boos (Jefe de departamento), Dr. Evelyn Eisenstein (sub-Jefe de departamento), Dr. Moh Sham Kasim, Dr. Randa Youssef, Dr. Patricia Lai Sheung Ip, Dr. Tufail Muhammad, Dr. Margaret Lynch and Dr. Randall Alexander Dr. Howard Dubowitz, Facilitador y Editor ISPCAN Apoyo al Personal

3 Escenario 1 Bebé de sexo masculino: USA Familia bajo estrés económicoBebé molesto (lloriqueando) Contusiones en las nalgas “Otitis” del oído medio Hematoma subdural Hemorragias extensas de la retina

4 Escenario 1 Bebé molesto (lloriqueando) Source: AAPAsk the audience if they have any suggestions as what may have happened. Infant crying can be very stressful for parents, and can increase the risk for maltreatment. Excessive crying may lead to caregiver fatigue, and feelings of frustration, anger, and/or inadequacy when efforts to soothe the baby are unsuccessful. The caregiver may direct this anger and frustration toward the baby, leading to abusive acts such as shaking, and/or slamming the baby down. The child has a subdural hematoma (bleeding in the space between the brain and skull – photo top right), fractured ribs (photo – bottom right) and extensive retinal hemorrhages (bleeding in the back of the eye – photo bottom left): classic findings of abusive head trauma or Shaken Baby Syndrome. This collection of findings is due to shaking the child forcefully while tightly squeezing the ribcage. The result is injury to the brain, eyes and rib fractures. Injuries to the ends of the arm and leg bones (metaphyseal fractures) can also occur from flailing of the extremities during shaking. The severity of symptoms is directly related to the force used. Often there may be a number of minor episodes of shaking with less severe symptoms initially such as irritablity, poor feeding, lethargy and to cry even more. This can lead to further episodes of shaking. 20 to 30% of babies who are injured this way die and many who survive have life long disabilities. 4

5 Discusión ¿Qué es abuso infantil?¿Qué tan comunes son el maltrato infantil, abuso físico infantil y el trauma de cabeza causado por abuso? ¿Las lesiones de Bobby fueron causadas por abuso infantil? ¿Cuál es el diagnóstico de Bobby? ¿Por qué el doctor no sospechó abuso infantil en Bobby en el chequeo de las dos semanas? Here are some of the questions about Bobby that we will be discussing.

6 ¿Qué es Maltrato Infantil?

7 Maltrato Infantil Todas las formas de maltrato físico y/o emocional, abuso sexual, negligencia o tratamiento negligente o explotación comercial (o de otro tipo), resultando en el daño real o potencial a la salud de un menor, a su sobrevivencia, a su desarrollo o a su dignidad en el contexto de una relación de confianza o poder. (Organización Mundial de la Salud 1999) This slide gives the formal definition of Child Abuse as developed by WHO in The key point is that acts of omission or commission that interfere with a child reaching his or her full potential are considered maltreatment. Acts of commission include physical and sexual assault as well as commercial and sexual exploitation, while acts of omission include various forms of neglect, such as nutritional neglect (lack of adequate food), educational neglect (lack of adequate education), and medical neglect (lack of adequate medical care, including mental health care). This is a good time to ask “What do you consider Child Maltreatment?” This is also the correct time to discuss terminology. The term child maltreatment will be used to include both abuse and neglect throughout this seminar. 7

8 Incidencia de Maltrato InfantilTasa por cada 1000 Incidencia de Maltrato Infantil Determining the frequency of child maltreatment is challenging. There are many sources of data on maltreatment, and some capture more cases than others. Here is an example of multiple data sources from the United States (1) NCANDS is the National Child Abuse and Neglect Data System. It includes only cases of maltreatment that are reported to state Child Protective Service (CPS) agencies. (2) NIS-4 is the 4th National Incidence Study on Child Abuse and Neglect. It contains cases of child maltreatment reported to CPS, but also contains cases of maltreatment that are known to professionals but not reported. (3) The self-report data comes from an anonymous telephone survey conducted in North and South Carolina, United States. As you can see, many incidents of maltreatment never come to the attention of CPS or other professionals 8

9 Incidencia de Maltrato InfantilTasa por cada 1000 Incidencia de Maltrato Infantil Data sources: World Health Organization. World report on violence and health, Chapter 3, Child abuse and neglect by parents and other caregivers. While official rates of child maltreatment in Canada are similar to those of the United States, worldwide estimates of physical and sexual abuse are much higher. 9

10 Los casos que conocemos son sólo la punta del icebergRemind the audience that none of the data sources mentioned previously can identify all episodes of child maltreatment. 10

11 Tasas de Castigo Físico ExcesivoRates and types of harsh physical punishment show much variation from one country to another. Actions considered acceptable by most people in one community, state, or country may be considered abuse elsewhere. Fuente: OMS (WHO) estudio WorldSAFE Runyan DK. Pediatrics. 2010;126:e701-11 11

12 Tasas de Castigo PsicológicoSome forms of psychological maltreatment are extremely common around the world. Again, the rates of different types of psychological maltreatment vary from country to country. Source: WHO WorldSAFE study 12

13 Trauma de Cabeza causado por abusoSacudida de bebés < 2 años Keenan: ICU admisiones y muertes Theodore: parental report Ask the readers why they think the rates are so different. Possible explanations: Keenan study: Misses non-ICU hospital admissions, emergency department, and outpatient visits, children who don’t get any medical attention Theodore study: shaking incidents may include many children who are not injured from more minor shaking Keenan, et al. JAMA. 2003;290:621-6 Theodore, et al. Pediatrics. 2005;115:e331-7 13

14 Las tasas de maltrato de menores son más altas de lo que la mayoría de las estadísticas “oficiales” sugieren Pero el maltrato de menores ¿Es acaso más común que otras condiciones de la infancia? 14

15 Comparación con Otras Condiciones de la InfanciaThese comparisons are taken from U.S. data, but make the point that child maltreatment is more common than many other childhood medical conditions. * Denota prevalencia. Las demás son tasas de incidencia 15

16 ¿Las Heridas de Bobby Fueron Causadas por Abuso Infantil?

17 Diagnóstico Diferencial#1 - Trauma #2 - Trauma #3 - Trauma While there may be conditions that cause each of these findings in isolation, the combination of subdural hemorrhage, extensive retinal hemorrhage, brain injury, and fractures is diagnostic for trauma, most likely from child abuse.

18 Diagnóstico Diferencial Hemorragia SubduralTrauma No causado Trastorno de sangrado Ruptura de aneurisma Ehlers-Danlos Glutaric aciduria tipo I Because each of Bobby’s findings can occur in isolation, it is important to consider the differential diagnosis for each individual finding. Ehlers-Danlos is a connective tissue disorder. Children with this condition have fragile and hyperelastic skin, easy bruising, and hypermobile joints. Glutaric aciduria type I is a metabolic disorder in which children develop seizures, abnormal movements, and loss of developmental milestones.

19 Diagnóstico Diferencial Hemorragia RetinalRecién nacido normal • Aneurisma Trastorno de sangrado • RCP Presión alta • Infección Trastorno metabólico Los puntos anteriores raramente causan una hemorragia extensa! Retinal hemorrhages can be seen in a number of medical conditions. However, they are generally few in number and confined to the posterior pole. Extensive retinal hemorrhages that extend to the periphery of the retina, and occur in multiple layers of the retina are very specific for child abuse. Extensive retinal hemorrhages are occasionally seen in crush injuries to the head. However, this diagnosis should be obvious from the history and clinical findings.

20 Diagnóstico Diferencial de Fracturas de CostillaTrauma no causado: debe haber una historia de trauma severo (ej., VCM, golpe directo) Herida de nacimiento: historia de partos difíciles Enfermedad de hueso metabólico: OI, Raquitismo, etc. Nacimiento prematuro extremo Ask the audience why rib fractures are uncommon in infants. Remind them that in young children, ribs are still predominantly composed of cartilage, and are therefore very flexible and are more likely to bend than break. There are still some conditions and injuries that can lead to rib fractures, and it is important to consider and rule out these possibilities when diagnosing abuse.

21 Fracturas de Costilla ALTA ESPECIFICIDAD DE ABUSOEspecialmente si son posteriores o laterales Usualmente ocultas Fractura de costilla aguda, se pasa por alto frecuentemente esp. si son anteriores o laterales Más fácil de ver en rayos-X cuando están sanando, después de 1-2 semanas. This x-ray shows healing rib fractures, indicated by the arrows. Remind the audience that when rib fractures heal, callus forms, leading to a rounded appearance on x-ray. This callus is often easier to identify than acute rib fractures, where it may be difficult to distinguish fracture lines from lung markings.

22 Fracturas de Costilla - Mecanismo que causa las heridasLa compresión del tórax causa el apalancamiento de las costillas posteriores sobre la columna vertebral . La compresión aplica tensión a lo largo de los aspectos internos de la cabeza de la costilla y región del cuello, provocando la fractura. Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO: Mosby, Inc p116.

23 ¿Cuál es el diagnóstico de Bobby?

24 TRAUMA DE CABEZA CAUSADO POR ABUSOES… CUALQUIER HERIDA CAUSADA EN LA CABEZA DE UN MENOR

25 Trauma de Cabeza causado por abusoSíndrome del Bebé Sacudido Shaking Impact Syndrome Trauma de Cabeza causado por abuso Many terms are used by professionals and lay persons to indicate abusive head trauma. The American Academy of Pediatrics recommends that professionals NOT use the term shaken baby syndrome, as it indicates a mechanism, rather than a diagnosis. However, shaken baby syndrome is a term that is often more familiar to lay audiences. Herida Cerebral Traumatica Causada iTBI

26 Definición Trauma de cabeza causado por abuso – cualquier herida causada a la cabeza de un menor Abarca “Síndrome del Bebé Sacudido” y “shaking-impact syndrome” Herida de Contacto y/o de no-contacto Inflicted injuries can include contact injuries (e.g. head hitting an object, object hitting the head, or object and head hitting each other) and non-contact injuries (i.e. shaking).

27 Epidemiologia Ocurre más comúnmente en infantesHerida causada por sacudida reportada en menores hasta de 5 años de edad Al menos 2/3 de las heridas serias de cabeza en infantes The highest rates of AHT are seen in infants, with epidemiologic studies providing rates of about 30 cases/100,000 children. Rates in children age 1-2 are about 17 per 100,000.

28 Hallazgos del DiagnósticoHemorragia subdural Hemorragia de la retina Herida Cerebral Fracturas – especialmente de costilla y metafiseal The diagnostic constellation of findings includes subdural and retinal hemorrhages, brain injury, and fractures.

29 Causas Potentiales Llorar Entrenamiento para ir al bañoPercepción de mal comportamiento Ninguna Crying is a common trigger for shaking or otherwise abusing an infant. The peak age for colic (~ 3 months) is also the peak ages for abusive head trauma. Abuse may result from the combination of a colicky baby who won’t stop crying, and a caregiver who is lacking sleep, frustrated because of his/her inability to calm the baby, and momentary loss of impulse control.

30 Señales y Síntomas MENOS SEVERO MAS SEVERO Convulsiones LetargoIrritabilidad Poco apetito Vómito MAS SEVERO Convulsiones Inconsciencia Respira con dificultad Muerte The signs and symptoms of abusive head trauma can be quite variable, depending on the severity of injury. Children with more severe injuries also have more obvious symptoms, including breathing difficulties, seizures, loss of consciousness, and possibly death. The diagnosis of abusive head trauma in children with less severe injuries may be missed, because symptoms such as lethargy, irritability, poor appetite, and vomiting are non-specific. These children may be diagnosed with reflux, colic, or gastroenteritis. Often the possibility of abuse is not considered.

31 ¿Porqué el doctor no sospechó abuso en el chequeo de las dos semanas?Ask the audience to come up with reasons why the doctor might not have diagnosed abuse, and why he/she might not have even considered abuse.

32 Colaboradores del Maltrato InfantilSociedad Comunidad Famila Padres Menor Developmental-Ecological theory posits that there are multiple and interacting factors that contribute to child maltreatment. These begin with the child, and extend outward to the society at large. Each level may interact with all other levels. Use this theory to begin a discussion about specific risk factors that might be included in each level Profesionales Belsky, Psychological Bulletin. 1993;114:413 32

33 Factores de Riesgo en MenoresEdad - Niños menores Sexo - - niñas: Alto riesgo de infanticidio, abuso sexual, negligencia educacional y nutricional. - niños: Alto riesgo de abuso fisico Caracteristicas Especiales – gemelos, menores discapacitados, prematuros, embarazos no deseados. Factors that increase a child’s risk for maltreatment include anything that might make a child more difficult to care for. These may include young age, handicap, or excessive crying. Gender is also a risk in specific ways. Provide the audience with the following example: A couple have a 6 week old baby who has become increasingly colicky. He cries incessantly throughout the evening. The parents cannot console the child for long, despite feeding, rocking and walking with him. He wakes several times at night, leaving both parents exhausted. The baby gets more irritable as the day goes on, and is at his worst when the father gets home from work in the evening. Ask the audience “what do you think might happen?” 33

34 Factores de Riesgo en Padres/GuardianesMuy jóvenes Padres solteros Embarazo no deseado Habilidades escasas como padres Abuso de drogas Enfermedad mental o física Any parent or caregiver characteristics that may increase stress in their lives may increase the risk of maltreatment. Some of these are lack of knowledge and experience in dealing with children and others are from outside pressures. Younger, single parents with little or no supports are one group that appears to have a high level of stress in their lives. Parents with substance abuse problems, mental health issues, relationship difficulties or have work related stresses are also at higher risk to lose control. To continue the example of the colicky infant, imagine the effect of her constant crying and the general difficulty in consoling her, on a caregiver who is drunk or angry with a spouse. Later on we will discuss prevention, but take a minute and ask the audience to “consider what we could do to help the parents and lessen the possibility of the child being maltreated.” 34

35 Factores de Riesgo FamiliaresCircunstancias de hacinamiento Pobreza Aislamiento Social Mucho estrés Violencia doméstica Family factors that increase stress can also contribute to maltreatment. Remind the audience about the parents with the colicky infant. The family lives in a low income apartment building where every sound is heard in the next apartment. The child cries for hours. Neighbours complain to the building superintendent, who tells the family if this continues they will have to move. The parents fight over how to stop the crying. This wakes the child, who begins to cry again. The neighbour bangs on the wall and shouts that if they can’t control the child he will come over and do something about it. Ask the audience “What happens now?” 35

36 Factores de Comunidad y SociedadLeyes de protección infantil nulas o pobremente implementadas. Falta de valoración de los niños Aceptación social de la violencia (familia, comunidad o de la sociedad – incluyendo la guerra) Normas Culturales Inequidades Sociales - pobreza Note that limited value of children can indicate all children, or specific groups of children (e.g. disabled, minority, Many societies look at physical discipline as every parent’s right and often their obligation. “Spare the rod, spoil the child” is a common saying. In some places children are not valued until they are old enough to contribute to the family. Still other cultures will restrict educational opportunities due to poverty and a lack of understanding of the need and value of education. On the other hand there are cultures where success is measured by the level of education of children and they justify harsh discipline as a tool to enforce school achievement. It is the weak groups in society; the elderly, women, the infirm and children who suffer the most from war, crime and violence in general. To continue the example of the crying infant; ask the audience “What if the father did beat or shake the child and no one cared? 36

37 Factores ProfesionalesFallar en: Reconocer que existe maltrato de menores Identificar y atender maltrato de menores Ofrecer servicios necesarios para los menores y sus familias Ayudar en la prevención del maltrato Al promover salud, desarrollo y seguridad Al atender factores de riesgo importantes

38 Discusión ¿Por que el doctor no sospechó abuso infantil cuando Bobby regresó con síntomas? Asumiendo que hubo abuso, ¿cuáles cree usted que sean las consecuencias del abuso de Bobby? ¿Por qué piensa usted que en esta familia pudo haber abuso? 38

39 ¿Por qué el doctor de Bobby no sospechó abuso cuando el regreso con síntomas?

40 Puntos de Enseñanza Los doctores buscan la respuesta en la historia sin considerar que la historia es difícil. Pensar que ha habido abuso es incomodo, particularmente en familias que son “amables” sobretodo con las que uno se puede identificar. Los traumas provocados están frecuentemente ocultos. As child health care providers, we depend a great deal on the information provided to us by parents. However, with child abuse, this history is often absent or misleading. Keep in mind that an absent history doesn’t mean that a caregiver is hiding something. It may be that the child was injured in someone else’s care, and this caregiver is unaware. 40

41 Presentación Clínica Hallazgos No-específicos+ Historia ausente o engañosa _______________________ Diagnóstico Erróneo The combination of non-specific findings and an absent or misleading history may lead to the diagnosis of abuse being missed.

42 Diagnóstico Erróneo Mas común en familias que son: De raza blancaQue tienen padres casados Tienen alto ingreso económico A paper published by Carole Jenny and colleagues in JAMA in 1999 showed that physicians were more likely to miss the diagnosis of abusive head trauma when the parents were white, married, and of higher income.

43 Qué se espera de las víctimasRetardo Mental Daño cerebral severo Problemas de aprendizaje Convulsiones Problemas de oído y del lenguaje Problemas de visión Desordenes de conducta Muerte Outcomes for victims can be quite variable, depending on the severity of the injury. Some children with more minor injuries may recover with only mild sequelae, e.g. learning or behavioral problems. Children with more severe injuries may have more serious sequelae, including death.

44 ¿Porqué cree usted que en esta familia pudo haber ocurrido abuso?Have the participants think about the risk factors present in this family, and how they may have resulted in abuse of this child.

45 Escenario 2 María – Madre adolescente, BrazilFue encontrada inconsciente, posible intento de suicidio Hijos de 3 meses y 4 años de edad – sucios, hambrientos, con posibles problemas de desarrollo Elena – Niña de 4 años de edad se masturba frecuentemente – examen físico es normal María fue sexualmente abusada cuando era niña

46 Discusión ¿Elena fue sexualmente abusada?¿Cómo es que el examen físico de Elena influencia su opinión? ¿Cuáles fueron las consecuencias del abuso de María cuando era una menor? Here are some of the questions that we will be discussing as we review what happened with Elena and Maria. 46

47 ¿Tanto Elena como su hermano han sido descuidados? Discusión ¿Tanto Elena como su hermano han sido descuidados? ¿Cuál es la relación entre las experiencias de María y el descuido y abuso sexual de sus hijos? Here are some of the questions that we will be discussing as we review what happened with Elena and Maria. 47

48 ¿Elena fue sexualmente abusada?

49 Abuso Sexual de MenoresInvolucramiento de un menor en actividad sexual que el/ella: no comprende completamente, es incapaz de dar consentimiento informado, no tiene un desarrollo que lo(a) prepare para tal actividad, Viola las leyes y tabúes de la sociedad Los menores pueden ser explotados por un adulto u otro menor quien por virtud de su edad o desarrollo, esta en una posición de responsabilidad, poder o confianza (fuente: ISPCAN & WHO in, “Preventing Child Maltreatment”, 2006) This definition of Sexual Maltreatment of children is also from “Preventing Child Maltreatment” (WHO & ISPCAN 2006). Simply stated it says that the involvement of children in sexual activity of any sort, by an adult or older child in a position of trust or power, is maltreatment. This form of maltreatment is often a very difficult type to identify and difficult to prove. You should ask the audience if sexual maltreatment is an issue in their community. In some communities sexual maltreatment, whether involving children or adults, is such a taboo that it is not accepted as something that happens there. 49

50 Abuso Sexual de MenoresOcurre a menudo como un asalto ‘oculto’ Todas las formas de actividad sexual están incluidas, no solo la penetración y otros tipos físicos Incluye prostitución de menores y exposición a la pornografía Sexual maltreatment not only includes the usual physical acts. It includes exposure to pornography and child prostitution. One point to make is that children are frequently reluctant to disclose sexual maltreatment and often not believed when they do. Studies indicate a child often has to tell several adults before someone listens to them. Even when they are believed most often there are no physical findings to prove a sexual contact took place. It is their word against that of the adult. The child may feel they have done something bad and be reluctant to disclose for this reason. 50

51 Características del perpetradorNo tiene un perfil típico Muchos parecen normales, exitosos y no tiene antecedentes criminales La mayoría son varones La mayoría están familiarizados con el menor, muchos en una posición de confianza o autoridad % son adolescentes Muchos (no todos) fueron abusados también While sexual assault perpetrated by strangers often garners the most media attention, most abusers are people whom the victims know and often trust.

52 Caracteristicas del MenorAproximadamente 85% del sexo femenino (casos conocidos en el sistema) Edades pico: Niñas y niños – edad pre-escolar 5-7 años Niñas – años Vulnerables, que necesitan mucha atención Ask the audience why this statistic about the percentage of girls vs. boys may be inaccurate. (Answer – boys may be more reluctant to disclose, may feel greater sense of shame, may fear being labeled as homosexual). Interviews with imprisoned perpetrators of sexual abuse indicate that they often look for children (and their caregivers) who are vulnerable and needy, as they are easier targets.

53 Formas para Identificar MenoresSeñales físicas: herida o infección El menor confía – en otro menor, padre, terapista, o adulto de confianza El menor abusa sexualmente de otro menor El menor usa lenguaje sexualmente obsceno, comportamiento mas adelantado a su desarrollo normal There are a number of ways that children who have been sexually abused may come to the attention of professionals. Physical injury and infection are the least common ways that children are identified – fewer than 5% of children who have been sexually abused have physical evidence of abuse. More often, a child’s statements or behavior lead someone to suspect abuse.

54 El examen normal de Elena ¿elimina la posibilidad de abuso sexual?Based on the information from the previous slide, the audience should be aware that most children who have been sexually abused have normal exams. Ask them to think about why this may be the case.

55 El Examen Médico - Hallazgos“Es normal ser normal” Más del 95% de los menores referidos tienen exámenes normales ¿¿¿Por qué??? Los actos de abuso no pueden dejar heridas (ej.. caricias) Causar heridas incrementa el riesgo de revelación Las heridas sanan a menudo sin dejar cicatriz antes de que haya revelación y evaluación médica.

56 La Evaluación Médica – Qué No es NormalHerida genital – Desgarres agudos, lesiones, marcas de mordidas Condición anormal, crónica – desgarres sanados de membrana, cicatrices Infecciones Sexualmente transmitidas Embarazo Evidencia forence – esperma, semen, etc. As noted in the prior slide, it is unusual for children to have abnormal exams. Genital injury, either acute or chronic, indicates that some trauma has occurred. If there is a history of sexual abuse, or an absence of any history of accidental injury, sexual abuse is very likely. Sexually transmitted infections may be transmitted perinatally, or may be from consensual sex in a teenager. However, outside of these periods, sexually transmitted infections such as gonorrhea, chlamydia, and syphilis are highly likely to be from sexual abuse. Herpes is also likely to be from sexual abuse. However, transmission through non-sexual means (e.g. a child with an oral herpes lesion touching her mouth and then her genital area) is possible. HIV may also be transmitted through sexual abuse, however, infection via perinatal transmission, IV drug use, or blood transfusion must also be considered.

57 Comportamiento Sexualizado en MenoresPosibles causas: Abuso sexual Pobre entendimiento de normas sociales ej.. Menor con discapacidades de desarrollo Curiosidad/exploración sexual Exposicion a actividades sexuales explícitas Atestiguó actividad en el hogar, en la TV, películas Viendo pornografía Puede estar inadvertido, descuidado, o abusivo Sexualized behavior in a child may lead to caregiver suspicions about the possibility of sexual abuse. While sexually explicit behavior can be a manifestation of abuse, other causes should also be considered. Some sexualized behavior may be imitation of behavior to which a child is exposed. For example, a child may witness sexual activity in the home. When space is limited, all family members may share the same sleeping quarters, making this exposure difficult to avoid completely. Children living in nations at war may be inadvertently (or purposefully) exposed to sexual assault of women by enemy forces. In homes with televisions and computers with internet access, sexually explicit material is pervasive, and easy to find. At times, exposure to sexually explicit activities or material may be completely inadvertent (e.g. a child unexpectedly entering a room where adults are having sex or viewing sexually explicit media). It is also possible that an adult is viewing explicit material or engaging in explicit activity without regard to the child’s presence. This behavior should be considered neglectful. Finally, an adult may expose a child to sexually explicit material as part of a victim grooming process. Young children, particularly in the preschool years, are curious about their own bodies, as well as those of the opposite sex. Looking, touching, and asking about genitalia may reflect this curiosity. Children may touch their genitals because it feels good, even though they have little or no understanding of sexuality. Children with developmental disabilities may have difficulty understanding societal norms, and may engage in sexual behavior such as masturbation because it feels good. These children may not understand that such behavior is not appropriate in public.

58 Conductas Comunes años (con poca probabilidad de estar relacionados con abuso) Friedrich WN. Normative sexual behavior in chidren. Pediatrics ; 101:e9 Niños 1) Se tocan partes sexuales en casa 2) Se tocan los pechos 3) Se paran muy cerca de otros 4) Tratan de ver a otras personas mientras están desnudas 5) Se tocan partes sexuales en publico 6) Se masturban con la mano Niñas Se tocan partes sexuales en casa Se tocan los pechos Tratan de ver a otras personas mientras están desnudas Se paran muy cerca de otros Se masturban con la mano Se tocan partes sexuales en público The data on the next several slides are based on research conducted by William Friedrich and colleagues. Parents of children who had not (to the best of the parents’ knowledge) been sexually abused reported on the behavior of their children. This slide shows the most common behaviors of boys and girls age 2-9 years. Note that the common behaviors in boys and girls in this age group are very similar.

59 Conductas Comunes años (con poca probabilidad de estar relacionados con abuso) Friedrich WN. Normative sexual behavior in chidren. Pediatrics ; 101:e9 Niños 1) Muy interesados en el sexo opuesto 2) Quieren ver desnudos en la TV 3) Tratan de ver fotos de gente desnuda 4) Saben mas acerca del sexo 5) Hablan acerca de actos sexuales 6) Se tocan partes sexuales en casa Niñas Muy interesadas en el sexo opuesto Saben mas acerca del sexo Se paran muy cerca Quieren ver desnudos en la TV Se tocan partes sexuales en casa Hablan acerca de actos sexuales This slide shows Friedrich’s study results for children in the preteen years. Again, the behaviors of boys and girls are similar, but there is more variation in the frequency of behavior among boys and girls in this age group, compared to the younger children.

60 Conductas poco comunes a los 2-12 años (más probables de estar relacionados con abuso)Pone la boca en partes sexuales Pide ser parte en actos sexuales Se masturba con objetos Se inserta objetos en la vagina/ano 5) Imita penetración Hace sonidos sexuales Trata de besar al “estilo frances” Desviste a otras personas Pide ver TV para adultos 10) Imita comportamiento sexual con muñecos This slide also shows data from Friedrich’s research. However, these are the behaviors that were least commonly reported by parents. It is important to note that these behaviors, while uncommon, do not automatically indicate abuse. However, they are red (or pink) flags that should trigger additional assessment of the child’s safety and potential inappropriate exposures.

61 Conductas que generan preocupaciónAtención excesiva en la sexualidad, conocimiento mas allá del desarrollo normal Conducta inapropiada a pesar de esfuerzos de redirección Conducta/exploración/intimidación sexual con niños mucho mayores/menores Causa daño a los genitales propios o de otros Comportamiento perturbador en el baño Predominio de dibujos con genitales Contacto sexual con animales These behaviors are worrisome, and should prompt additional assessment.

62 Cuáles fueron las consequencias del abuso sexual para Maria?

63 Impacto del Abuso Sexual– Salud FísicaCorto plazo: Heridas agudas Enfermedades de transmisión sexual Largo plazo: Problemas gastrointestinales (irritabilidad de intestino) Dolor Crónico (dolor de cabeza, abdominal, de espalda, o pélvico) Obesidad, imposibilidad de triunfar en la vida Somatización Long term cohort studies and retrospective studies have shown a variety of impacts of CSA on adult health, both physical….

64 Impacto del Abuso Sexual– Salud MentalProblemas de conducta – muy tímido, revelándose, delincuencia Depresión PSTD & otros trastornos de ansiedad Abuso de substancias Trastornos de la alimentación – anorexia, bulimia Fracaso en la escuela Baja auto-estima, dificultades interpersonales And mental..

65 ¿Acaso Elena y su hermano han sido victimas de neglicencia?Ask the audience whether Elena and her brother have been neglected. Remember that when found, Elena and her brother were dirty and hungry. They both appeared to have developmental delays.

66 Definición of Neglicencia Centrada en el MenorLa negligencia ocurre cuando las necesidades básicas de un menor no han sido satisfechas, resultando en posibilidad o existencia de daño físico. Las necesidades básicas incluyen adecuada: Alimentación - Vestimenta Supervisión - Protección Atención médica - Educación Amor y cuidados - Hogar Rather than blaming a caregiver for what they fail to do, many experts advocate for using a child-centered definition, described above. Review the definition, then have the group come up with a list of basic needs. Sometimes the entire responsibility can be ascribed to a single individual (or set of parents). Often, however, the situation is more complicated, and the responsibility for ensuring children’s basic needs lies in many hands, including health care providers, schools, and government. It appears clear that Elena and her brother were not receiving adequate food. Their developmental delays may indicate inadequate maternal bonding and nurturance. Maria may have attempted suicide and was found unconscious. Therefore Elena and her brother were not receiving adequate supervision. 66

67 ¿Cuál es la relación entre las experiencias de Maria y la negligencia y abuso sexual de sus hijos?Ask the audience to think about which long-term effects Maria may have suffered, and how they may relate to the sexual abuse and neglect of Elena. For example, as a result of her own sexual abuse, Maria may be dealing with depression and PTSD. These conditions may make it difficult for her to meet the basic needs of her children. They may also make it difficult for Maria to take steps to keep her children safe from abuse and exploitation. In addition, Maria may suffer from low self esteem and difficulty forming healthy relationships. She may therefore choose partners who take advantage of her and her children. Finally, her partner may have targeted Maria and her children because of the children’s neediness, and Maria’s inability to protect them.

68 Puntos de Enseñanza Todas las formas de maltrato se incrementan con factores de riesgo social, especialmente la pobreza El abuso sexual es el problema menos relacionado La negligencia es el más relacionado Todas las formas de abuso suceden en todos los grupos étnicos, sociales y económicos

69 Puntos de Enseñanza AdicionalesLas acusaciones falsas son raras Las negaciones falsas son comunes Los niños abusados sexualmente a menudo llegan a ser testigos indiferentes Escapan de casa Niños de la calle “Delincuentes”

70 Puntos de Enseñanza Negligencia: no cubrir las necesidades/derechos básicas de un niño Emocional Nutricional Vivienda Seguridad Salud Educación

71 Puntos de Enseñanza La negligencia puede verse como algo benignoNo lo es Tiene efectos potenciales muy serios : Físicos: ej., bajo crecimiento, ingestión, muerte Cognitivos: ej., retraso en el desarrollo, problemas de aprendizaje De salud mental: ej., problemas emocionales y de conducta Sociales: Delincuencia juvenil y comportamiento criminal

72 Escenario 3 Hombre de mediana edad : ChinaEnfermedades físicas y psicosomáticas Abuso de tabaco y alcohol Golpeado cuando era niño Testigo de violencia domestica Terminó su relación con su “mentor” Aislado socialmente

73 Discusión ¿Cuáles “experiences adversas de la niñez” puede usted identificar o sospechar? ¿Qué cree usted que pasó entre Lao Zhang y su mentor? ¿Pudo haber sido abuso sexual? Ask the audience, “Which of Lao Zhang’s experiences growing up might be considered adverse childhood experiences?” and “What other childhood events might be considered adverse childhood experiences?” Abuse and neglect should definitely be considered adverse childhood experiences (sometimes called ACEs). Witnessing domestic violence could also be considered an ACE (and many experts would also consider this to be child maltreatment). Other ACEs include death of a parent, natural disasters such as earthquakes or floods, war, or famine.

74 Discusión ¿Qué consecuencias posibles de conducta pueden estar relacionadas con las experiencias de la infancia de Lao Zhang? ¿Qué consecuencias médicas han ocurrido o pueden ocurrir en un paciente como Lao Zhang? Ask the audience to think about possible behavioral, medical, and mental health consequences of ACEs. 74

75 El impacto del Maltrato en los NiñosTodo menor es afectado – la extensión del daño varía Factores múltiples determinan el impacto: Naturaleza del maltrato Personalidad del menor Factores de protección Las consecuencias pueden ser: Físicas Psicológicas De conducta Sociales In this section we will look at the impact of child maltreatment on children. This slide notes the important point that every child is affected by maltreatment. However, it recognizes the degree of the impact is variable dependant on the type and intensity of the abuse and the presence of protective factors. Ask the audience, “What are some examples of these consequences?” 75

76 Consecuencias FísicasLesiones ej. fracturas, quemaduras, lesiones a órganos internos, laceraciones, lesiones de cabeza Trastornos de desarrollo cerebral Discapacidad a corto y largo plazo Muerte Some of the consequences, such as those associated with Physical Maltreatment are more obvious. Broken bones, lacerations and other physical injuries are easily identified. Longer term effects such as impaired brain development secondary to head injury may not be obvious initially but cause life long difficulty for the child who was injured. 76

77 Probabilidad de adquirir cardiopatía isquémica mostrado por el número de experiencias adversas de la niñez This slide looks specifically at how increasing ACE scores influence the odds of ischemic heart disease in adults. The authors controlled for medical and psychosocial risk factors, as these can also contribute to ischemic heart disease. 77

78 Consecuencias PsicológicasComunes Pueden incluir: Problemas inmediatos de aislamiento, miedo y falta de confianza problemas de por vida de depresión , baja auto-estima, dificultad con relaciones Trastornos de desarrollo cognitivo Children may develop both short-term and long-term psychological consequences from maltreatment. Some examples are listed in this slide. More details follow in subsequent slides. 78

79 Riesgo de suicidio por Score ACEChild maltreatment can lead to long-term mental health consequences. This data is also from the ACE study. In this study, adults with 4 or more adverse childhood experiences had 12 x the odds of suicide compared to adults with no adverse childhood experiences. 79

80 Puntos de Enseñanza Mucha gente mayor sufrió de algún abuso que no veían como abuso o que no querían discutir Esto es particularmente verdadero cuando se trata de abuso sexual en niños Los menores pueden ser seriamente afectados cuando son testigos de violencia doméstica

81 Puntos de Enseñanza “Experiencias adversas de la niñez” pueden tener efectos de salud a largo plazo Problemas de Salud (ej. cardiopatía) Problemas de salud mental (ej., depresión, tendencia al suicidio) ¿Vulnerabilidad debida al estrés, o al aislamiento social?

82 Escenario 4 Niña de seis años de edad A los siete meses de edad:Fractura de fémur sintomática Fracturas de costilla (pasadas y nuevas) “lesiones clásicas metafisarias” Protegida Tratada con la familia Reunificada

83 Preguntas de Discusión¿Qué cree usted que causó las múltiples fracturas de Palwasha? ¿Qué le pudo haber pasado a Palwasha cuando la retiraron? ¿Qué servicios pueden ser de ayuda para Palwasha y su familia?

84 Cuales son las posibles causas de las múltiples fracturas de Palwasha?Seems impossible to answer most of these. 84

85 Diagnóstico Diferencial de Fracturas de Huesos LargosAbuso Infantil Lesiones accidentales Trastornos médicos que incrementan el riezgo de fracturas Osteogenésis imperfecta Raquitismo While abuse is the most common cause of fractures in children this young, other causes need to be considered. Severe accidental injury can cause one or more fractures, however, this should be clear from the history. Some medical disorders can also cause easy fractures in young children, and should also be considered. Osteogenesis imperfecta is a disorder of collagen synthesis that can lead to easy fractures. There are several different forms of this disorder. The more severe forms should be obvious because of bone abnormalities present at birth. The less severe forms may not be obvious. Some additional traits that may be seen in osteogenesis imperfecta are blue sclerae, hearing loss (or family history of hearing loss), dentinogenesis imperfecta (teeth that easily break and decay), and family history of easy and frequent fractures. Rickets is a bone disease that results from inadequate vitamin D stores. Risk factors for rickets include dark skin, limited sun exposure, and inadequate vitamin D intake from breast milk or formula. The bones of children with rickets may show tenderness, rachitic rosary (bumps along the ribs), frontal bossing (prominence of the forehead), and thickening of the wrists and ankles. This condition can be identified and distinguished from abuse through laboratory testing. 85

86 Fracturas de Huesos LargosBaja especificidad para abuso EXCEPTO EN BEBÉS (menores que no caminan todavía) Fractura espiral o oblicua: no-específica Indica fuerza torsional Long bone fractures are very common, and are more often the result of accidental injury than the are from abuse. The exception to this rule is in infants. Their lack of mobility makes it unlikely that they will injure themselves. There is a common misconception that spiral fractures are very specific for abuse. However, recent clinical and biomechanical studies have shown that accidental spiral fractures can occur. The spiral appearance indicates only that a torsional or twisting force caused the fracture. The spiral appearance does not indicate whether the injury is abusive or not.

87 Fracturas de Hueso Largo– FemurPatrones Comunes accidentales: Caer al ir corriendo, especialmente con un movimiento de torsion En una caida con torsion mientras el pie se encuentra bien plantado Las fracturas de Femur levantan muchas sospechas de abuso en menores que todavia no caminan In ambulatory (walking) children, femur fractures occur commonly in the two instances noted above.

88 Fracturas de Hueso Largo– HúmeroFracturas “Shaft” Considerar edad del menor el historial médico de la herida Supracondylar fx Debido a una caída en el codo Accidental en su mayoría Mayor posibilidad de abuso en bebés As with the femur, fractures of the humerus are more often accidental than inflicted. However, in non-mobile children, abuse is much more likelly. A common accidental humeral fracture is the supracondylar fracture. This is a fracture of the distal humerus that is often the result of a fall onto the elbow.

89 Fracturas de Hueso Largo – TibiaFractura “Toddler” Oblicua, fractura no-desplazada de la tibia distal Historia de un traumatismo menor o no traumatismo En bebés y menores que acaban de aprender a caminar. ACCIDENTAL A common accidental tibia fracture is the toddler’s fracture, described above.

90 Fracturas de Hueso Largo– Lesión Clásica Metafiseal (CML)“Corner” o “bucket-handle” dependiendo de la vista Mecanismo: torciendo o jalando una extremidad o por las fuerzas de aceleración/desaceleración durante una sacudida ALTAMENTE ESPECIFICA DE ABUSO The classic metaphyseal lesion is seen in infants, at the metaphysis. Depending of the angle of the x-ray, it can have the appearance of a corner fracture (left-sided images) or a bucket handle fracture (right sided images). These fractures are highly specific for abuse in infants. They typically occur from twisting or pulling of an extremity, or from acceleration/deceleration forces that can occur during shaking.

91 RESUMEN – DIAGNOSTICO Especificidad de FracturasALTA MODERADA BAJA CML Multiple fx, esp. bilateral Subperiosteal new bone Rib Fx de diferentes edades Clavicula Scapula Separacion epiphyseal Long bone shaft Spinous process Cuerpo vertebral Linear skull Sternum fx Dedos de manos y pies fx Complex skull Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO: Mosby, Inc P 9. This slide shows a summary of the specificity of various fractures for physical abuse. Among the fractures with a high specificity of abuse, we have already discussed rib fractures and classic metaphyseal fractures. Fractures of the scapula, spinous process and sternum are uncommon under any circumstances, and require a significant amount of force. In the absence of a history of severe injury, such as a motor vehicle crash, these fractures are diagnostic for abuse.

92 ¿Qué le pudo haber pasado a Palwasha cuando fue retirada?The answer to this question depends on the systems and resources available in Palwasha’s community. She may have been placed in foster care. If extended family was available to serve as a resource, she may have been placed in kinship care. Ideally, Palwasha’s parents (or the person responsible for her injuries) would receive services such as parenting education and anger management. An ideal system would also assess Palwasha’s family for maltreatment risk factors such as parental depression, intimate partner violence, substance abuse, etc. If Palwasha had siblings, they would also be assessed for possible maltreatment. Finally, Palwasha would be provided with trauma-focused counseling to prevent long-term mental health sequelae. 92

93 Discusión ¿Qué sistema existe en su comunidad para proteger menores abusados? ¿Cómo activa usted ese sistema? ¿Qué servicios existen en su comunidad para tratar a menores abusados, a los miembros de su familia que no han sido abusados, y aquellos que abusan de los menores? These questions are intended to generate discussion among participants. Every country, state, and/or region has a different system for addressing child abuse and neglect. And all have different resources available to help families in which maltreatment has occurred. Participants can explain the processes in their own region, and discuss what components work well, and what could be improved.

94 Puntos de Enseñanza : Pasos para Ayudar a Menores AbusadosIdentifique el abuso Detenga el abuso, prevenga nuevos abusos Trate las consecuencias medicas Y emocionales Apoye a la familia – ayude a hacer su entorno seguro O Encuentre una vivienda alterna que sea segura

95 Puntos de Enseñanza Sin embargo…Muchos menores abusados sufren de problemas por el resto de sus vidas Sin embargo… Muchos menores abusados se convierten en adultos exitosos Children are incredibly resilient. Many children have protective factors such as strong social support or self-efficacy that help protect them from long term negative outcomes

96 Para pedir una copia electronica . . .Mande un correo electronico a:

97 Puntos de Enseñanza ¿Cómo se provee la proteccion en su sistema social / legal? ¿Qué puede hacer usted para mejorar eso? ¿Qué tratamiento esta disponible para menores abusados y sus familias? ¿Cómo se puede mejorar el acceso?

98 Puntos de Enseñanza Hasta una tercera parte de los casos de traumatismo de cabeza, se pasan por alto en la primera presentacion. 27% re-incidencia de abuso 40% complicaciones 7% mueren 98

99 Puntos de Enseñanza El abuso sexual presenta muchas formas de: HeridasInfecciones sexualmente transmitidas Revelación Cambios emocionales y de conducta Trastorno de estrés postraumático (PTSD) 99

100 Puntos de Enseñanza > 90% de los examenes físicos son normalesCaricias Sexo oral y anal Sanación de heridas variación anatomica 100

101 Puntos de Enseñanza Las muchas consecuencias del abuso a futuro :PTSD, depresión, suicidio Trastorno de conducta, problemas en la escuela, uso de drogas Actividad sexual temprana, embarazo, Infecciones de transmisión sexual, HIV 101

102 Discusión ¿Cuáles son las consecuencias hasta el momento de la negligencia de los hijos de María? ¿Cuáles factores sociales, de medio ambiente, y familiares contribuyeron a esta situación? 102

103 Discusión ¿Cuáles son los derechos legales de Maria para quedarse con sus hijos? ¿Cuáles son los derechos y responsabilidades de Paulo para ayudar, sostener y visitar a sus hijos?

104 Puntos de Enseñanza ¿Cuáles son los derechos y responsabilidades de la familia? María Paulo Familia extendida ¿Cuál es la habilidad del sistema social para sustituir o sostener a la familia? 104