Text: Child abuse
Although abuses of every kind or any kind is against law and is punishable, child abuse perhaps is the most devastating crime because the children are defenseless. More often the abused child succumbs to such injuries and the offender goes unpunished. Psychiatrists may be able to show different reasons for adults abusing children.
The abuse can be simply physical assaults or may even be sexual abuses. Child abuse is relatively better evaluated and recorded in well developed countries where most families live in total privacy. In India where the families live together more often the other members of the family get involved in watching the children, and so major child abuses may not be frequently seen in the lower strata of the society. However, children living in single family dwellings are occasionally found to be abused physically and at time sexually. It leaves behind irreparable trauma in the growth and minds of these children. Many times the abuse may follow a well intended, but some what exaggerated form of punishment for indiscipline. More often even literate and affluent families fail to realize that punishment by physical abuse is against law. This kind of exaggerated punishment has been recorded even in elementary and primary schools where angry and frustrated teachers assault children utilizing canes and scales. Such instances, when noticed by the family practitioner, should be promptly reported to the authorities and appropriate action taken against the offenders.
The diagnosis of "abused child" is by no means easy. For example the infant having frequent seizures at times may do so because of cerebral hemorrhage caused by vigorous shaking of the head by a parent or whoever is taking care of the child. Any time a child comes with a fracture it is better to examine the rest of the body to make sure that there are no other healing fractures and that there are no other evidences of injuries in other parts of the body. When a child comes with frequent fractures child abuse must be ruled out before any other diagnostic possibility is considered. X-rays may reveal healing fractures with callus formation in different stages. In some children injured by leather belt being applied over the chest and/or abdomen, internal injuries may be present without any marks outside. Children sometimes develop scalds in both feet and legs due to immersion in hot water. In such cases the history given by the family is rather vague and even if the mother knows the person who is causing the problem to her child she may try to protect his/her interest to save the name of the family or for fear of being abused herself.
The following are some useful points to remember in approaching the diagnosis of child abuse and its management:
1. A complete history obtained in privacy in the presence of a nurse, by the doctor
2. Appropriate record keeping and clear documentation of injuries with photographs when necessary
3. Specific required test and x-ray where relevant
4. Retaining the copies of test reports for documentation
5. Reassure the patient (victim of abuse) on ability to care for without getting the patient into more trouble.
6. Discuss issues with parents individually and get the support and cooperation
7. Explain short term and long term trauma to the victims
8. Explain the need for psychiatric treatment of the one who is causing the offence as well as counseling for the victim.
9. Make sure the patient and the family understand that the care is indeed a team approach which includes other consultants, nurses, social workers, psychiatrists and at times legal experts.
10. Head to toe physical examination including complete neurological examination, fundoscopy and examination of the genitalia and rectum.
11. Provide medical, psychosocial and legal management of the case
12. Male or female make sure of any sexual abuses
13. Concerns of sexual abuse include
a. injuries to the genitalia
b. sexually transmitted disease
d. legal issues
e. psychosocial trauma
All these elements have to be carefully examined, recorded and appropriately managed.
1. Child abuse is more prevalent in any society than is commonly recognized.
2. Unless suspected child abuse may go undiagnosed
3. Connection with children should be established with truthful concern and care
4. Proper management of child abuse includes a careful diagnosis and team approach with specialists in related subjects as well as psychosocial, legal experts.
5. Follow up of these children should be mandatory
6. Follow up includes frequent visit to psychiatrist for further counseling as necessary.
Text: Adult abuse:
As cited in the cases above, adults also get abused by their siblings, children, parents-in-laws, spouse etc. This variety of domestic violence and the abuse on handicapped people and people who cannot properly defend themselves due to various reasons, visit doctors with different complaints. Only careful physical examination and a patient history taking will reveal some of these problems. Although family practitioners may not have solutions for every domestic problem, he can certainly contribute to improve the situation by giving them appropriate guidance with the help of his team as well as social workers, psychiatrists and the law.
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