‘Red Flags’ that Suggest Possible Abuse
There is no definite way to identify child abuse; however, there are some signs which help suspect and verify its occurrence. Physical abuse most often manifests itself in injuries and bruises (Hoft & Haddad, 2017). Another important detail to observe is the history of getting injured reported by a child. A ‘Red Flag’ here would be its inconsistency when the history is repeated. Hoft and Haddad (2017) suggest that other physical abuse signs include “delay in arriving at the emergency setting without a satisfactory explanation, suspicion after a head-to-toe examination, and other unexplained injuries in the history” (p. 29). The locations of bruises of concern to a professional are the torso, ears, and neck (Gonzalez et al., 2020). The ‘Red Flags’ related to a type of injury are retinal hemorrhages, posterior rib fractures, and metaphyseal lesions (Gonzalez et al., 2020). Signs of psychological abuse include poor hygiene, signs of malnutrition, withdrawal from social interaction, and developmental milestones delays (Adigun et al., 2020). Observing these signs should result in further examination and assessment.
Sexual abuse is harder to identify during a routine check since there may be no direct signs of it. Gonzalez et al. (2020) state that ‘Red Flags’ of this type of maltreatment manifest themselves in behavior. They include “undressing in front of others, touching others’ genitals, as well as trying to look at others when undressing” (Gonzalez et al., 2020, para. 23). Adigun et al. (2020) also offer a list of physical indicators. They include non-specific symptoms such as abdominal pain, fecal incontinence, constipation, and genital bruising or bleeding.
Differentiating Abuse from Neglect
It is essential to differentiate between child neglect and child abuse. The World Health Organization (WHO, 2020) puts them under an umbrella term “child maltreatment.” As Gonzalez et al. (2020) state, “abuse is defined as an act of commission and neglect is defined as an act of omission” (para. 1). Thus, abuse is related to harmful actions towards children, which can be both conscious and unconscious. Signs of these types of maltreatment also differ, and Tennyson Center for Children (2020) suggests a list of signs to differentiate between child neglect and abuse. Those of the latter are the children’s lack of medical or dental care, immunizations, or lack of glasses. They also include their frequent absence from school, begging for or stealing food or money, deficiency of clothing for the weather, and subjective children’s reports on the absence of someone at home to provide care. In general, the lack of adult supervision is the “umbrella” sign of neglect. Child abuse, in its turn, displays a different set of signs. They include disclosure of maltreatment, reluctance to be around a particular person, demonstration of a sudden change in behavior or school performance, and the presence of unexplained bruises or injuries. However, these signs are vague and serve as a mere incentive for further assessment.
One of the significant problems with defining child abuse in cross-cultural settings is that there are no objective criteria for what can be undoubtedly identified as child abuse. Some practices which can seem abusive in the sense that they cause children pain, suffering, or harm may not represent child abuse since they are collective expressions of cultural values (WHO, 2020). In such situations, not only adults but also children themselves do not categorize such actions as abusive; instead, they view those practices as having a longstanding positive value, for instance, the initiation rite.
One of the most controversial aspects of collecting subjective indicators of wellbeing is the fact that they may not coincide with objective indicators and often draw a completely opposite picture. In these terms, “subjective indicators” refer to children’s estimation of abuse and violence, whether they feel abused or they are “objectively” abused. Weight is often given to objective data, and subjective indicators are often criticized for unreliability.
Examination: Techniques to Verify the Suspicion of Abuse
One of the crucial techniques of child abuse suspicion verification is obtaining historical information. Adigun et al. (2020) state that victims of abuse can exhibit typical presenting complaints, which indicate the necessity to distinguish between symptoms of medical diagnosis and child abuse. Obtaining historical records continuously allows a nurse to check for a history of trauma in a patient with severe injuries. The absence of it signifies a high chance of physical abuse occurrence. Another technique related to obtaining history is checking its consistency when a child reports on how they got an injury. It is essential to obtain a history from the caregiver as well. The criteria for suspicion verification are the caregiver’s inability to give details about the child’s medical history, their attempts at answering for the patient, and the general inconsistency in history presentation or denial/underestimation of important details. The second basic technique is the physical examination, in which a healthcare professional checks the patient for the ‘Red Flags’ presence. In some cases, further evaluation is needed, for example, imaging studies and laboratory testing. These procedures allow for further assessment of the physical wellbeing of a patient.
A regular physical examination of a child does not exclude sexual abuse. Gonzalez et al. (2020) state that most of the victims of this type of maltreatment have a normal anogenital examination. Thus, the strongest sign of sexual abuse occurrence is the child’s report. Salvani and Wagner (as cited in Hoft & Haddad, 2017) suggest a tool for sexual abuse identification that addresses five questions. They include: “(1) sudden emotional and/or behavioral changes; (2) fear of being alone with a specific person; (3) unusual interest in sex or genitals, (4) changes in recreational activities; and (5) presence of anal or genital lesions” (Hoft & Haddad, 2017, p. 30). Thus, techniques for sexual abuse assessment rely on psychological techniques rather than physical examination.
Responsibilities of the Advanced Practice Nurse (APRN) in California
Most of the responsibilities of the APRN in California are related to both assessment and reporting. California is a state in the United States which is included in The Federal Child Abuse Prevention and Treatment Act (CAPTA), which imposes on nurses the requirement to report child abuse (Child Welfare Information Gateway, 2019). Since in the initial case with A.B. a routine school physical is performed, the APRN is also involved in “institutional responsibility to report.” They work in the situation clinical settings are intrinsically linked with institutional settings – school (Child Welfare Information Gateway, 2019). Ethical concerns involve, first of all, the fundamental principles of the healthcare profession, such as “do not harm.” Based on this, the APRN must ensure that their suspicion is verified sufficiently since, although the government requires to report child abuse, sometimes a false or inaccurate report can ruin the child’s and the caregiver’s lives. Thus, the APRN’s responsibilities include evaluating, assessing, reporting on child abuse, and taking part in creating information for further dissemination, including public reports.
References
Adigun, O. O., Mikhail, A. G., & Hatcher, J. D. (2020). Abuse and neglect. StatPearls.
Child Welfare Information Gateway. (2019). Mandatory reporters of child abuse and neglect. U.S. Department of Health and Human Services, Children’s Bureau. Web.
Gonzalez, D., Mirabal, A. B., & McCall, J. D. (2020). Child abuse and neglect. StatPearls.
Hoft, M., & Haddad, L. (2017). Screening children for abuse and neglect: A review of the literature. Journal of Forensic Nursing, 13(1), 26−34.
Tennyson Center for Children. (2020). About child abuse. Web.
World Health Organization. (2020). Child maltreatment.