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    Identifying and responding to child and elder abuse

    All healthcare professionals, including technicians, are mandated reporters

    Mary A. O'Hara, MDEach day, five children die in the United States from abuse or neglect. Three quarters of these children are under age 3.1

    Abuse and neglect data are equally grim for the elderly. About 10 percent of elders age 60 years and older have suffered abuse.2

    Keeping an eye out for abuse

    In light of these statistics, healthcare professionals need to be aware of the signs of child and elder abuse and their responsibilities in reporting abuse to the appropriate authorities.

    Forty percent of abused children will have ocular findings. In 5 percent of cases, an eye problem will be the initial complaint. Because the ophthalmic technician is often the victim’s first contact within the ophthalmic home, it is important that technicians are familiar with the aspects of history and examination that are characteristic of abuse cases.

    When taking a history, technicians should note incompatible injuries wherein the history of injury does not match the damage produced. In addition, wounds in different stages of healing without good history to explain multiple traumas should raise suspicions. Mouth wounds and skin burns are commonly seen in abused children. Another key point in the history are delays to care and multiple hospitalizations in different medical facilities without good explanation.

    Related: Understanding the techniques of eye removal

    Abuse of children

    Children who have been sexually abused will often exhibit behaviors that are overly sexual or fearful. Children will somaticize, complaining about stomachaches; new onset bed-wetting has also been reported. The diagnosis of a sexually transmitted disease in a young child who is “sexually naïve” can confirm suspicions.

    Children who are emotionally abused can also somaticize with new onset of headaches and stomachaches. A sudden change in self-confidence and abnormal fears may develop as well as failure to thrive in the younger child. The older child may develop a voracious appetite. 

    Ocular signs of physical abuse are similar to other traumas. Ecchymoses, hemorrhages around and within the eye, and signs of direct trauma such as subluxated lenses, cataract, atrophy of the optic nerve, and choroid or retinal scars are all suspicious within the context of an incompatible history of trauma.

    A particular type of physical abuse in the infant was identified by Caffey in 1974, “shaken baby” syndrome.3 This condition, now called abusive head trauma (AHT) occurs when the young child is shaken, dropped, or sustains direct blows to the head. Children with this condition rarely show outward signs of trauma but often will sustain brain damage and suffer from seizures.Figure 1. Typical retinal hemorrhages seen with abusive head trauma of an infant.

    The eyecare professional becomes key to the diagnosis by detecting retinal hemorrhages associated with AHT and documenting them with retinal photographs. The sequelae of AHT are grim. One third of children die from their injuries. Many surviving children will suffer brain damage from their injuries. Premature infants, children with multiple medical problems or developmental delay are at increased risk of AHT.3

    A careful history and a thorough examination are important when a healthcare professional suspects child abuse. Masquerade syndromes like osteogenesis imperfecta, nutritional deficiencies, hereditary sensory neuropathy and congenital syphilis may be mistaken for abusive injuries. However, most of these conditions can be distinguished through appropriate testing.

    In the same way, “bruises” may actually be Mongolian spots seen in deeply pigmented babies, or conditions associated with easy bruising such as coagulopathies, vasculitis, certain malignancies, or exposure to salicylates or rodenticides. Cultural therapies such as cupping, coining or moxibustion (the burning of traditional Chinese medicine herbs on or near the skin) can also leave marks. Although these treatments are non-conventional, they are not usually abusive in nature. In addition, Florida and other states grant exemption from prosecution to parents who choose spiritual healing rather than conventional medical therapy.

    When approaching suspected victims of child abuse, it is important to emphasize that they are in a safe place. Listen to their feelings in a non-judgmental way. Assure them it is OK to feel sad, confused, or scared about what’s going on. Tell them it’s not their fault—children assume they are abused because they are “bad.” It is important for the healthcare professional to reassure them that is not the case.

    Mary A. O'Hara, MD
    Mary O'Hara, MD, is a professor in the departments of ophthalmology and pediatrics at the University of California, Davis. She is a ...


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