Case Study 1 13 Instructions: Read the scenario below and answer the questions as it relates to the case presented.
A 5-year-old boy is brought to your office for a well-child checkup, accompanied by his father, mother, and 2 older siblings. He was reported to be healthy, but upon examination, you discover a 2-centimeter linear bruise on his palm. When asked about the bruise, the father says that a few days earlier he had spanked the boy with a belt and the child had put his hand behind him, resulting in the injury. The child had no other bruises or signs of abuse.
1. Is this a case of physical abuse?
2. Should this case be reported?
Questions for case study: Commentary: Spanking a child is a parenting behavior that can fall into a gray area of physical abuse. In this case, the child clearly suffered some bodily injury that involved significant pain and the injury resulted from the deliberate action of the parent, hence it would meet the legal definitions in Pennsylvania of physical abuse. The fact that it can be difficult to decide whether to report suspected abuse does not negate one’s professional and legal responsibility to protect children by doing so. Physicians are not responsible for determining whether maltreatment occurred, only for reporting reasonable suspicion. Physicians may reduce the burden of deciding whether or not to report a suspected case by participating regularly in continuing education related to child maltreatment, familiarizing themselves with reporting laws and local child protective services staff, and consulting with colleagues.
Child Sexual Abuse
Who Are The Perpetrators? Research suggests that no more than 10%- 30% of perpetrators of child sexual abuse were strangers. 15 In 90% of child sexual abuse cases, the offenders are male and are often described as being unassertive, withdrawn, and emotionless. 14 Other common characteristics include a history of abuse (either physical or sexual), alcohol or drug abuse, little satisfaction with sexual relationships with adults, lack of emotional control, and mental illness. Females can also be perpetrators, but they tend to use persuasion rather than force or the threat of force to control victims (boys are more likely than girls to be abused by a female). 14 What Are the Effects of Child Sexual Abuse? The effects of sexual abuse extend far beyond childhood. Sexual abuse robs children of their childhood and creates a loss of trust, feelings of guilt and self-abusive behavior. It can lead to antisocial behavior, depression, identity confusion, loss of self-esteem and other serious emotional problems. It can also lead to difficulty with intimate relationships later in life. Some long-term consequences of sexual abuse include impaired trust, self-destructive behaviors (e.g., cutting, anorexia), hopelessness, depression, and low self-esteem. 14 Other long-term effects can include increased risks for: • Teen pregnancy, either as victim or perpetrator. In one study, men who were sexually abused before age 10 were 80% more likely than non- abused men to later engage in sexual activity resulting in teen pregnancy. 16 • Homelessness. A study of homeless women found that childhood maltreatment, including physical, verbal, and sexual abuse, was a
“pervasive and devastating predictor of dysfunctional outcomes,” including chronic homelessness. 17 • Drug and alcohol abuse. Research suggests that both women and men who have experienced child sexual abuse have an increased risk of drug and alcohol abuse in their adult life. 18 Signs of Sexual Abuse Although sexually abused children may be too frightened to report the abuse the following physical signs may suggest abuse: 14 vaginal or rectal bleeding; genital pain, itching, swelling, or discharge; difficulty with bowel movements, urinating, or swallowing; recurring complaints of stomachaches and/or headaches; trauma to breasts, buttocks, lower abdomen, or genital or rectal areas; torn, stained, or bloody undergarments; vaginal infections; venereal diseases, or difficulty walking or sitting. Behavioral signs of child sexual abuse include extreme changes in behavior (loss of appetite, eating disorder, clinginess, withdrawal, aggressiveness); recurrent nightmares, disturbed sleep patterns, or a sudden fear of the dark; regression to infantile behavior (bed-wetting, thumb sucking, excessive crying); fear of a particular person or fear of being left alone with a particular person or at a particular place; frequent lying, and delinquent behavior; or a fall in grades at school. These children may also express unusual interest in or knowledge about sexual matters, express affection in inappropriate ways (for a child his or her age), and even engage other children in sexual activities or act out sexual behaviors (such as intercourse or masturbation). In addition, the victims may have poor relationships with other children, lack self-confidence, or engage in self-destructive behavior (biting oneself, pulling out hair, wrist-cutting).
What Is Child Sexual Abuse? At the extreme end of the spectrum, sexual abuse includes sexual intercourse or its deviations. Yet all offenses that involve sexually touching a child, as well as non-touching offenses and sexual exploitation, are just as harmful and devastating to a child’s well-being. 14 What is Sexual Abuse under Pennsylvania CPSL Child Abuse Laws? Child abuse applies under Pennsylvania’s CPSL when intentionally, knowingly or recklessly: • Causing sexual abuse or exploitation of a child through any act or failure to act • Creating a reasonable likelihood of bodily injury to a child through any recent act or failure to act • See Sexual Abuse and Sexual Misconduct definitions under the “Specific Acts of Child Abuse Defined in Detail” section Who are the Victims? Sexual abuse can occur in all populations. It happens to children in both rural and urban areas, in all socioeconomic and educational levels, and across all racial and cultural groups. 14 Statistics indicate that girls are more frequently the victims of sexual abuse, but that the number of boys is also significant. Estimates suggest that males account for 25-35% of child sexual abuse victims. 15 Factors that may increase a child’s risk of sexual abuse include being between the ages of 7 and 13, having an absent parent, and being isolated, depressed, or lonely. 14 A child is also at increased risk if he or she is forced to assume the parenting role at an inappropriate age.
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