Child Abuse Injuries: Part 2/2

April is Child Abuse Awareness Month. Last post, I covered how a given history for an injury may be a signal that an injury was intentionally inflicted. Today, I’m going to cover how the injury itself may give off clues for an abusive injury.

Injuries suspicious of abuse:

1. Injury is beyond the child’s developmental level: You’ll notice this is the first clue I gave concerning the history, but it also plays into the injury itself and I’m going to talk specifically about infants. Any bruising in an infant to the face, head and neck when they are not yet pulling themselves up to a standing position is concerning for abuse. To create an injury, you have to fall off of or run into something and you need to have some velocity behind it.

2. The injury has a pattern: Consider typical childhood bruises. They are roundish in shape, of varying circumferences, and received from a low-velocity type injury . . . say the child running into a counter with their forehead. Anything that makes a visible pattern generally requires high-velocity force to imprint the pattern onto the skin. If I loop a belt and tap you with it, there likely won’t be any injury at all versus if I take it and swing it at you like a pitcher throwing a baseball, it has the potential to create a loop like bruise.

3. The injury in not over a bony prominence: Again, if you have children, think back to their younger days when injuries were common. When they fell, where did they bruise? Head (scalp, forehead, nose, chin), elbows, shins, and knees. Most often, kids fall or run into something in a forward motion. Bruising to the buttocks in a diapered child is particularly concerning. Often, they will fall onto their bottoms, but they also have extra padding.

4. There are a lot of bruises: This is not definitive but can be a signal for abusive injury, particularly if the pattern is not a normal bruising pattern as in #3.

None of these items is taken in isolation as a single indictment against the caregiver. Let’s say you accidentally drop a toy onto your 2 month old’s face while cleaning up. It causes a bruise and you want it checked by the pediatrician. The pediatrician is not going to report you. Why? You have a plausible story (dropping something onto the baby’s face), it is a low velocity injury (the bruise is probably small and round) and there is only one.

Medical professionals look at the totality of the child’s case: the history, the social environment, and the injury is considered before a report to child services is made. Reports are not made lightly.

The above offers some beginning guidelines. In the comments section, give a specific injury that might be concerning for abuse.

Child Abuse Injuries: Part 1/2

I read a lot of fiction. Okay, suspense fiction. What I find missing is an area that seems to be in few books yet inherently has a lot of conflict. Child abuse. What fiction titles are you aware of that, as a central theme, center around child abuse?

April is Child Abuse Awareness Month so I thought I’d do a few posts about child abuse injuries and how medical providers pick up on the fact an injury may be intentional or inflicted.

As a pediatric nurse, I’ve been witness to child homicide at the hands of abuse. Yes, it is murder. It’s a necessary part of my job in dealing with these families, perhaps even the confessed abuser, as I care for the child abuse victim. And yes, there is a lot of conflict in these situations.

How do we as pediatric medical providers begin to suspect that an injury is abusive? During the initial evaluation of an injury, confession among abusers is rare (perhaps, they will confess later.) Often, there is a history given to account for the injury. Both parts: the history of the injury and the injury itself can give red flags for child abuse. Today, let’s examine the story and how it may signal an abusive injury.

The story concerning the injury:

1. Is not realistic considering the child’s developmental level. This is more common than you might think. Most people cannot rattle off when a child should meet certain developmental milestones so they’ll say the child injured themselves in a manner that is beyond their developmental age. For instance, “my daughter broke her arm by rolling off the couch”. The baby is two-weeks old. Infants typically roll over starting at 3 months. Here’s a great resource for any writer/parent for developmental milestones.

2. The story changes. Just like other criminals, abusers can have a hard time keeping their story straight. Often times, the more abusers are questioned about the plausibility of the story, it will begin to change. Medical staff interviewing a potential abuser can be like a detective getting a criminal to confess. The doctor will often approach the caregiver several times to ask questions about the injury to see if the story changes. In later interviews, the doctor may say, “This injury is suggestive of abuse.”

3. The story has too much detail. This one may seem odd but it can be a red flag for abusive injuries. If you have children, think back to their toddler/elementary school years when they seem to come home with lots of bumps, bruises, cuts and scrapes. If asked, could you come up with an explanation for each and every injury? Likely, no. Abusers will try and explain away every injury. A non-abusive parent will be truthful and likely say, “I have no idea how that happened.” and then probably feel guilty about not knowing.

What other parts of a medical history/story might give a signal for abusive injury?

Book Review: In The Name of God

In The Name of God delves into the ramifications of religious shield laws which (thank heavens this is changing) grant protection under the law if a child dies of a treatable medical illness and due to the parent’s religious beliefs– they refused medical care.

This touches close to me as a pediatric ER nurse seeing parents refuse some aspects of medical care– immunizations would be the largest. As a parent, I believe in my right to make decisions for my children, but as a pediatric nurse, I also believe that children deserve a certain level of medical care to grow up strong and healthy. The line between these two are not always clear.

Refusing immunizations pales in comparison to what these religious groups do– who believe that God is the ultimate healer and that if God decides– their child will be healed from illness. Sadly, these kids die from highly treatable conditions like pneumonia, cysts, prematurity, diabetes, and urinary obstructions. The strange thing is, The Followers don’t seem to have trouble going to the dentist or eye doctor.

The book alternates perspective between the legal side (those trying to change these laws) and inside views of The Followers as a religious group.

The book is interesting but really needed to be pared down. I don’t need to read a play by play of a child’s vomiting and throwing up each meal over two days to get the point that they couldn’t hold anything down. Also, I don’t think it’s necessary to give gory details about a pediatric autopsy– using words like, “This doctor was going to eviscerate . . . ” I think it’s disrespectful of a pediatric victim to do that. The intimate look into The Followers, in my opinion, became overindulgent and tedious to read.

That being said, I do think this is an important, challenging book and in this era of religious extremes, I think those of us that have faith need to speak out against the extremes of our faith and I applaud this book for doing so in a balanced way.

Parents Behaving Badly: The Case of Justin Ross Harris

As a pediatric nurse, I’ve been intrigued by the case of Justin Ross Harris, who is accused of killing his son by leaving him in a hot car.

This is one of those things, personally, that I do kind of scratch my head at. I know people get stressed. I could even understand leaving a child behind for a few moments before your rationale brain kicked in and said, “Hey, the baby’s in the car.”

I mean, we treat phones so much better.

He has pled innocent but this CNN HLN article brings up some interesting points that came from his hearing that I thought I would highlight here. These come directly from their piece.

1. It was a normal morning. Meaning, he was the one who usually took his kid to school. It wan’t unusual for them to stop at Chik-fil-A for breakfast. When you do things repeatedly, there’s less room for error.

2. It’s a short distance from Chik-fil-A to his daycare. Like one minute. So, in one minute, he loaded his son up in the car but then forgot he was there.

3. You could see the child from the rear view mirror. This is a pretty interesting point. Evidently, Harris backed into his parking spot. He doesn’t have a rear view camera so would have had to look in his mirror. When they placed a mannequin of similar size in that seat it was visible in the mirror.

4. Bizarre behavior. Witnesses felt like he was “working” at being emotional.

5. Strange statements. One alleged statement: “I dreaded how he would look.”

6. Additional Injuries. Abrasions to the back of the head.

7. Sexting. Harris was sexting six different women as his son died including sending explicit photos.

8. Life Insurance. The child had two life insurance policies on their son and might have been in financial trouble from credit card use.

9. Internet Activity. Disturbing internet searches for videos with people dying, how to be child-free, how to survive prison and the age of consent for Georgia.

10. Harris is deaf in his right ear. This is used by the defense to perhaps explain that he didn’t hear his son in the car.

Whatever happens in this case, one good thing that might come from these deaths is the invention from one teen, designed to alert parents if they do accidentally leave their child in the car.

What do you think from what you’ve hear of the Harris case? Do you think he committed murder?

Mothers Behaving Badly: 2/2

April was Child Abuse Prevention month. Obviously, this holds a place close to my heart as I deal with victims of abuse with needless frequency. Needless because these injuries are 100% preventable.

Image Link

I’m continuing my series on infanticide cases of note that have happened recently. You can read my last post here on the Megan Huntsman case.

This story from People magazine caught my eye because the prosecution involved in this woman’s case alleges she breastfed her baby to death.
 
In short, during the infant’s first month of life, it only gained four ounces. Average weight gain is 0.5-1 oz per day for around 15oz on the lighter side.
 
Then: At 6 weeks old, she died, and an autopsy found enough morphine in her brain, liver and blood to kill an adult. With no puncture marks or other trauma, Alexis – authorities concluded – could only have gotten the drug through breast-feeding.
 
Question #1: Does morphine pass through breast milk? Yes, it does. The concerning issue for me is that one of the major side effects of opiate ingestion is bodily systemic depression. Everything slows down. The patient gets sleepy and their HR, respiratory rate and heart rate can be lower. You need a somewhat awake infant to feed. Seemingly, it is alleged the baby became toxic through breast milk ingestion only because of the lack of trauma. However, I think it should be considered that she also could have directly given the baby medicine.
 
Question #2: Is the sole source of breast milk enough to cause this level of poisoning? I do have issue with this statement. I think it should be considered that she also could have directly given the baby morphine. It turns out the baby’s mother, Stephanie Greene, is a nurse. She would have the know how to directly give the baby morphine and I wonder if this was considered during her trial. Evidently, her nursing “skills” were brought up during the trial in the fact that she doctor shopped for all her scripts. I think this is common among drug users and I don’t think her nursing knowledge was particularly helpful in this area– but it could have been with the administration of the drug to her baby.
 
More attention should be paid to this, especially considering her attorney states there’s never been a US death associated with breast feeding and morphine. To me, this makes direct administration more plausible and sadly, it would not be that difficult to do.
 
She has been sentenced to 20 years in prison.
 
In light of April being Child Abuse Prevention month– please remember you might be the only one to save a child’s life. Report suspicion of child abuse. 
 

Mothers Behaving Badly: 1/2

I would be remiss as a pediatric ER RN to not mention that April is Child Abuse Prevention month. Every April comes around and I think I shouldn’t talk about child abuse this year. Haven’t we overcome this as a society? I delayed it most of the month until we had a significant child abuse case come in to our emergency department.

It appears we still need to talk about it. People are still injuring and killing their children.

I thought I would discuss two interesting cases of recent note.

One is the case of Utah woman Megan Huntsman. I know– ironic last name, isn’t it?

Ms. Huntsman is accused of murdering six of seven infants and then disposing of them in her garage in cardboard boxes. Authorities think one of the babies was stillborn. They were discovered by her ex-husband as he was cleaning out the home in order to move in. Authorities think this happened over a 10 year period from 1996-2006. What’s interesting is that Megan evidently hid her pregnancies from everyone. Neighbors noticed that her weight would vacillate between wearing baggy clothes and tight clothes. They never imagined she was hiding pregnancies. DNA testing is pending to ensure these are her children.

What’s curious is that she had a daughter born during this time frame that was allowed to live. What was the choice behind allowing this child to grow-up?

Huntsman evidently has told police that she is responsible for their deaths either by strangulation or suffocation. What she doesn’t say is why.

What’s frustrating from a medical/human perspective is that Utah has a Safe Haven law which allows a person to drop off newborn infants without fear of prosecution if the infant is unharmed.

I’m guessing– but I think this likely would have been a short car ride down the street.

You can read more about Megan Huntman’s case here and here.

Book Review of The Psychology of Dexter: Part 1/3

Frequent followers of this blog know I’m a fan of the television show Dexter– not necessarily for its medical accuracy but for its amazing plot and character development. Honestly, I wish I would have been the author to create a series about a vigilante serial murderer working for the police department.

Sheer genius. You can read some of my medical analysis of Dexter here and here.

So, of course, I was intrigued when I found the non-fiction book The Psychology of Dexter that includes a collection of essays on various topics analyzing the show from different mental aspects and, over the next few posts, I’m going to highlight some interesting tidbits I learned along the way.

The first essay I found interesting was titled Rethinking Dexter by Lisa Firestone, PhD. What follows are quotes from the actual book or are very close paraphrases. This particular essay dealt with childhood PTSD and  whether or not early treatment of psychopathic children could reduce their violent nature in the future.

1. “Research shows that a child’s cruelty toward animals almost always arises out of an abusive family environment. Humane education that focuses on developing empathy toward animals generalizes to empathy for human beings. The National District Attorney Association suggests that targeted therapy at this could save future lives.”

2. “Research suggests that psychopaths almost always are treatable if they receive intensive therapy for a proper duration of time.” which throws out the theory that there is not hope for these types of people.

3. “Studies have shown that almost 100% of children who witness parental homicide develop PTSD because of the severity of the traumatic event. Eighty percent of children that have been imprisoned, rendered immobile in some way (buried alive, tied up, or tortured) will develop PTSD as well.”

4. “Childhood trauma has an impact on actual brain development. It can cause serious structural abnormalities in the frontal lobe, known as ‘the seat of emotion.’ Brain researchers have found that these abnormalities often result in deep-seated personality deficits such as an inability to be empathetic.”

4. “When childhood events are traumatic enough to cause PTSD, children dissociate from themselves as the helpless victim and identify instead with the aggressor. They identify with the very person who is hurting them, who they see as strong and not vulnerable to the type of pain they are experiencing. This is the only survival strategy available to the child.”

5. “An additional common symptom of early childhood PTSD is post-traumatic play, in which children repeat themes or aspects of the trauma they experienced. This does not relieve anxiety.”

Are you surprised by any of this information as it relates to childhood PTSD?