Formation de base sur la maltraitance des enfants

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1 Formation de base sur la maltraitance des enfants
Pour les professionnels de la santé

2 Etabli par l’équipe chargée du développement des programmes médicaux de l’ISPCAN
Membres : Dr. Steve Boos (Président), Dr. Evelyn Eisenstein (Présidente), Dr. Moh Sham Kasim, Dr. Randa Youssef, Dr. Patricia Lai Sheung Ip, Dr. Tufail Muhammad, Dr. Margaret Lynch et Dr. Randall Alexander Dr. Howard Dubowitz, Facilitateur et Rédacteur Avec l’aide du personnel de l’ISPCAN

3 Vignette 1 Bébé de sexe masculin : USA
Famille en difficulté économique Bébé intense et difficile Ecchymoses sur les fesses “Otite moyenne” Hématome sous-dural Hémorragies rétiniennes étendues

4 Vignette 1 Bébé intense et difficile Source: AAP
Ask the audience if they have any suggestions as what may have happened. Infant crying can be very stressful for parents, and can increase the risk for maltreatment. Excessive crying may lead to caregiver fatigue, and feelings of frustration, anger, and/or inadequacy when efforts to soothe the baby are unsuccessful. The caregiver may direct this anger and frustration toward the baby, leading to abusive acts such as shaking, and/or slamming the baby down. The child has a subdural hematoma (bleeding in the space between the brain and skull – photo top right), fractured ribs (photo – bottom right) and extensive retinal hemorrhages (bleeding in the back of the eye – photo bottom left): classic findings of abusive head trauma or Shaken Baby Syndrome. This collection of findings is due to shaking the child forcefully while tightly squeezing the ribcage. The result is injury to the brain, eyes and rib fractures. Injuries to the ends of the arm and leg bones (metaphyseal fractures) can also occur from flailing of the extremities during shaking. The severity of symptoms is directly related to the force used. Often there may be a number of minor episodes of shaking with less severe symptoms initially such as irritablity, poor feeding, lethargy and to cry even more. This can lead to further episodes of shaking. 20 to 30% of babies who are injured this way die and many who survive have life long disabilities. 4

5 Discussion Qu’est-ce que l’abus envers les enfants?
La maltraitance, l’abus physique et les blessures de la tête dues à la violence sont-ils courants ? Les blessures de Bobby sont-elles dues à la maltraitance? Quel est le diagnostic au sujet de Bobby ? Pourquoi le médecin n’a pas soupçonné l’abus lors de l’examen des 2 semaines ? Here are some of the questions about Bobby that we will be discussing.

6 Qu’est-ce que la maltraitance envers les enfants?

7 Maltraitance des enfants
La maltraitance de l’enfant s’entend de toutes les formes de mauvais traitements physiques et/ ou affectifs, de sévices sexuels, de négligence ou de traitement négligent, ou d’exploitation commerciale ou autre, entraînant un préjudice réel ou potentiel pour la santé de l’enfant, sa survie, son développement ou sa dignité dans le contexte d’une relation de responsabilité, de confiance ou de pouvoir (Organisation Mondiale de la Santé 1999) This slide gives the formal definition of Child Abuse as developed by WHO in The key point is that acts of omission or commission that interfere with a child reaching his or her full potential are considered maltreatment. Acts of commission include physical and sexual assault as well as commercial and sexual exploitation, while acts of omission include various forms of neglect, such as nutritional neglect (lack of adequate food), educational neglect (lack of adequate education), and medical neglect (lack of adequate medical care, including mental health care). This is a good time to ask “What do you consider Child Maltreatment?” This is also the correct time to discuss terminology. The term child maltreatment will be used to include both abuse and neglect throughout this seminar. 7

8 Incidence de la maltraitance
Rate per 1000 Incidence de la maltraitance Taux pour 1000 Determining the frequency of child maltreatment is challenging. There are many sources of data on maltreatment, and some capture more cases than others. Here is an example of multiple data sources from the United States (1) NCANDS is the National Child Abuse and Neglect Data System. It includes only cases of maltreatment that are reported to state Child Protective Service (CPS) agencies. (2) NIS-4 is the 4th National Incidence Study on Child Abuse and Neglect. It contains cases of child maltreatment reported to CPS, but also contains cases of maltreatment that are known to professionals but not reported. (3) The self-report data comes from an anonymous telephone survey conducted in North and South Carolina, United States. As you can see, many incidents of maltreatment never come to the attention of CPS or other professionals Abus Abus Négligence Total physique sexuel 8

9 Incidence de la maltraitance
Rate per 1000 Incidence de la maltraitance Taux pour 1000 Data sources: World Health Organization. World report on violence and health, Chapter 3, Child abuse and neglect by parents and other caregivers. While official rates of child maltreatment in Canada are similar to those of the United States, worldwide estimates of physical and sexual abuse are much higher. Abus physique Abus sexuel 9

10 Les cas reconnus ne forment que le sommet de l’iceberg
Remind the audience that none of the data sources mentioned previously can identify all episodes of child maltreatment. 10

11 Taux de punitions corporelles sévères
Rates and types of harsh physical punishment show much variation from one country to another. Actions considered acceptable by most people in one community, state, or country may be considered abuse elsewhere. Source: WHO WorldSAFE study Runyan DK. Pediatrics. 2010;126:e701-11 11

12 Taux de punition psychologique
Some forms of psychological maltreatment are extremely common around the world. Again, the rates of different types of psychological maltreatment vary from country to country. Source: WHO WorldSAFE study 12

13 Traumatisme à la tête dû à l’abus
Secouement des enfants < 2 years Keenan: Admissions et décès en soins intensifs Theodore: Récit des parents Ask the readers why they think the rates are so different. Possible explanations: Keenan study: Misses non-ICU hospital admissions, emergency department, and outpatient visits, children who don’t get any medical attention Theodore study: shaking incidents may include many children who are not injured from more minor shaking Keenan, et al. JAMA. 2003;290:621-6 Theodore, et al. Pediatrics. 2005;115:e331-7 13

14 Les chiffres de la maltraitance des enfants sont plus élevés que ce que les statistiques “officielles” laissent entendre Mais la maltraitance est-elle plus répandue que d’autres conditions affligeant les enfants ?? 14

15 Comparaison avec d’autres conditions affectant les enfants
These comparisons are taken from U.S. data, but make the point that child maltreatment is more common than many other childhood medical conditions. * Montre la prévalence. Les autres, taux d’incidence 15

16 Les blessures de Bobby sont-elles dues à la maltraitance envers les enfants ?

17 Diagnostic différentiel
#1 - Traumatisme #2 - Traumatisme #3 - Traumatisme While there may be conditions that cause each of these findings in isolation, the combination of subdural hemorrhage, extensive retinal hemorrhage, brain injury, and fractures is diagnostic for trauma, most likely from child abuse.

18 Diagnostic différentiel Hémorrhagie sous-durale
Traumatisme non-infligé Troubles du saignement Rupture d’anévrisme Ehlers-Danlos Acidurie glutarique type I Because each of Bobby’s findings can occur in isolation, it is important to consider the differential diagnosis for each individual finding. Ehlers-Danlos is a connective tissue disorder. Children with this condition have fragile and hyperelastic skin, easy bruising, and hypermobile joints. Glutaric aciduria type I is a metabolic disorder in which children develop seizures, abnormal movements, and loss of developmental milestones.

19 Diagnostic différentiel Hémorragie rétinienne
Normal chez nouveau-né Anévrisme Troubles de saignement • RCP Tension élévée • Infection Trouble métabolique Ces conditions ne causent que rarement des hémorragies rétiniennes étendues Retinal hemorrhages can be seen in a number of medical conditions. However, they are generally few in number and confined to the posterior pole. Extensive retinal hemorrhages that extend to the periphery of the retina, and occur in multiple layers of the retina are very specific for child abuse. Extensive retinal hemorrhages are occasionally seen in crush injuries to the head. However, this diagnosis should be obvious from the history and clinical findings.

20 Diagnostic différentiel des fractures des côtes
Traumatisme non infligé : Le récit d’un sévère traumatisme devrait exister (ex:, AVP, coup direct) Blessure à la naissance: Histoire d’un accouchement difficile Maladie osseuse métabolique : OI, rachitisme, etc. Bébé très prématuré Ask the audience why rib fractures are uncommon in infants. Remind them that in young children, ribs are still predominantly composed of cartilage, and are therefore very flexible and are more likely to bend than break. There are still some conditions and injuries that can lead to rib fractures, and it is important to consider and rule out these possibilities when diagnosing abuse.

21 Fracture des côtes TRES COMMUNES LORS D’ABUS
Surtout si postérieures ou latéraless Souvent latentes Aiguës fractures souvent non décelées, surtout si antérieures ou latérales Plus faciles à déceler sur radio lors de la guérison, après 1 ou 2 semaines. This x-ray shows healing rib fractures, indicated by the arrows. Remind the audience that when rib fractures heal, callus forms, leading to a rounded appearance on x-ray. This callus is often easier to identify than acute rib fractures, where it may be difficult to distinguish fracture lines from lung markings.

22 Fractures des côtes - Mécanisme lésionnel
La compression du thorax appuie sur les côtes postérieures qui font levier sur les vertèbres. La compression cause une tension sur la face interne des côtes, région tête et cou, provoquant la fracture. Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO: Mosby, Inc p116.

23 Quel est le diagnostic au sujet de Bobby

24 LE TRAUMATISME ABUSIF DE LA TETE
est… TOUTE BLESSURE INFLIGEE A LA TETE D’UN ENFANT

25 Abusive Head Trauma iTBI Shaken baby syndrome Shaking Impact Syndrome
Many terms are used by professionals and lay persons to indicate abusive head trauma. The American Academy of Pediatrics recommends that professionals NOT use the term shaken baby syndrome, as it indicates a mechanism, rather than a diagnosis. However, shaken baby syndrome is a term that is often more familiar to lay audiences. Inflicted Traumatic Brain Injury iTBI

26 Définition Traumatisme abusif de la tête – toute blessure infligée à la tête d’un enfant Inclut “le syndrome du bébé secoué” et le “shaking-impact syndrome” (secouement et impact) Blessure avec contact/sans contact Inflicted injuries can include contact injuries (e.g. head hitting an object, object hitting the head, or object and head hitting each other) and non-contact injuries (i.e. shaking).

27 Epidémiologie Plus fréquent chez les bébés
Fractures dues au secouement rapportées chez des enfants jusqu’à 5 ans Au moins 2/3 des blessures sérieuses de la tête chez les bébés The highest rates of AHT are seen in infants, with epidemiologic studies providing rates of about 30 cases/100,000 children. Rates in children age 1-2 are about 17 per 100,000.

28 Eléments du diagnostic
Hémorragie sous-durale Hémorragie rétinienne Lésion cérébrale Fractures – surtout costales et métaphysaires The diagnostic constellation of findings includes subdural and retinal hemorrhages, brain injury, and fractures.

29 Déclencheurs potentiels
Pleurs Apprentissage du pot Perception de mauvaise conduite Aucun Crying is a common trigger for shaking or otherwise abusing an infant. The peak age for colic (~ 3 months) is also the peak ages for abusive head trauma. Abuse may result from the combination of a colicky baby who won’t stop crying, and a caregiver who is lacking sleep, frustrated because of his/her inability to calm the baby, and momentary loss of impulse control.

30 Signes et symptômes PLUS SEVERES Crise convulsive MOINS SEVERES
Perte de connaissance Difficultés de respiration Décès MOINS SEVERES Léthargie Irritabilité Manque d’appétit Vomissements The signs and symptoms of abusive head trauma can be quite variable, depending on the severity of injury. Children with more severe injuries also have more obvious symptoms, including breathing difficulties, seizures, loss of consciousness, and possibly death. The diagnosis of abusive head trauma in children with less severe injuries may be missed, because symptoms such as lethargy, irritability, poor appetite, and vomiting are non-specific. These children may be diagnosed with reflux, colic, or gastroenteritis. Often the possibility of abuse is not considered.

31 Pourquoi le médecin n’a pas soupçonné l’abus lors de la visite des 2 semaines?
Ask the audience to come up with reasons why the doctor might not have diagnosed abuse, and why he/she might not have even considered abuse.

32 Facteurs de la maltraitance
Société Communauté Famille Parents Enfant Developmental-Ecological theory posits that there are multiple and interacting factors that contribute to child maltreatment. These begin with the child, and extend outward to the society at large. Each level may interact with all other levels. Use this theory to begin a discussion about specific risk factors that might be included in each level Professionnels Belsky, Psychological Bulletin. 1993;114:413 32

33 Facteurs de risque Age – enfants très jeunes Sexe -
- filles: risque accrû d’infanticide, abus sexuel, carence éducationnelle et nutritionnelle. - garçons: risque accrû d’abuse physique Caractéristiques – jumeaux, enfants handicapés, prématurés, non désirés Factors that increase a child’s risk for maltreatment include anything that might make a child more difficult to care for. These may include young age, handicap, or excessive crying. Gender is also a risk in specific ways. Provide the audience with the following example: A couple have a 6 week old baby who has become increasingly colicky. He cries incessantly throughout the evening. The parents cannot console the child for long, despite feeding, rocking and walking with him. He wakes several times at night, leaving both parents exhausted. The baby gets more irritable as the day goes on, and is at his worst when the father gets home from work in the evening. Ask the audience “what do you think might happen?” 33

34 Facteurs de risque du parent
Jeunesse Parent seul Grossesse non désirée Peu de compétences parentales Toxicomanie Maladie physique ou mentale Any parent or caregiver characteristics that may increase stress in their lives may increase the risk of maltreatment. Some of these are lack of knowledge and experience in dealing with children and others are from outside pressures. Younger, single parents with little or no supports are one group that appears to have a high level of stress in their lives. Parents with substance abuse problems, mental health issues, relationship difficulties or have work related stresses are also at higher risk to lose control. To continue the example of the colicky infant, imagine the effect of her constant crying and the general difficulty in consoling her, on a caregiver who is drunk or angry with a spouse. Later on we will discuss prevention, but take a minute and ask the audience to “consider what we could do to help the parents and lessen the possibility of the child being maltreated.” 34

35 Facteurs de risques familiaux
Conditions de vie difficiles (manque d’espace) Pauvreté Isolement social Stress important Violence domestique Family factors that increase stress can also contribute to maltreatment. Remind the audience about the parents with the colicky infant. The family lives in a low income apartment building where every sound is heard in the next apartment. The child cries for hours. Neighbours complain to the building superintendent, who tells the family if this continues they will have to move. The parents fight over how to stop the crying. This wakes the child, who begins to cry again. The neighbour bangs on the wall and shouts that if they can’t control the child he will come over and do something about it. Ask the audience “What happens now?” 35

36 Facteurs de société/communauté
Lois de protection de l’enfance peu ou pas appliquées Manque de valeur des enfants Acceptation de la violence (famille, communauté,société, – guerre incluse) Normes culturelles Injustices sociales - pauvreté Note that limited value of children can indicate all children, or specific groups of children (e.g. disabled, minority, Many societies look at physical discipline as every parent’s right and often their obligation. “Spare the rod, spoil the child” is a common saying. In some places children are not valued until they are old enough to contribute to the family. Still other cultures will restrict educational opportunities due to poverty and a lack of understanding of the need and value of education. On the other hand there are cultures where success is measured by the level of education of children and they justify harsh discipline as a tool to enforce school achievement. It is the weak groups in society; the elderly, women, the infirm and children who suffer the most from war, crime and violence in general. To continue the example of the crying infant; ask the audience “What if the father did beat or shake the child and no one cared? 36

37 Facteurs professionnels
Incapacité à: Admettre que la maltraitance existe Reconnaître et à traiter la maltraitance des enfants Offrir les services nécessaires à l’enfant et à sa famille Aider à prévenir la maltraitance En encourageant la bonne santé,le développement et la sécurité En essayant d’éliminer les facteurs de risque principaux

38 Discussion Pourquoi le médecin n’a pas soupçonné un cas de maltraitance lorsque Bobby est revenu avec des symptômes ? En supposant la maltraitance , quelles sont à votre avis les conséquences de la violence contre Bobby? A votre avis, pour quelles raisons familiales y a-t-il eu maltraitance? 38

39 Pourquoi le médecin n’a pas soupçonné un cas de maltraitance lorsque Bobby est revenu avec des symptômes?

40 A retenir Les médecins cherchent la réponse dans l’histoire de cas ; il leur est difficile de ne pas considérer l’histoire. Envisager l’abus met mal à l’aise surtout dans des familles “bien” qui paraissent sympathiques Les traumatismes infligés sont souvent latents As child health care providers, we depend a great deal on the information provided to us by parents. However, with child abuse, this history is often absent or misleading. Keep in mind that an absent history doesn’t mean that a caregiver is hiding something. It may be that the child was injured in someone else’s care, and this caregiver is unaware. 40

41 Présentation clinique
Résultats non spécifiques + Histoire absente ou trompeuse _______________________ Abus non diagnostiqués The combination of non-specific findings and an absent or misleading history may lead to the diagnosis of abuse being missed.

42 Abus non diagnostiqués
Plus souvent dans le cas de familles : De race blanche Dont les parents sont mariés D’un milieu économique élevé A paper published by Carole Jenny and colleagues in JAMA in 1999 showed that physicians were more likely to miss the diagnosis of abusive head trauma when the parents were white, married, and of higher income.

43 Conséquences pour les victimes
Arriération mentale Lésion cérébrale sévère Difficultés d’apprentissage Crises convulsives Troubles de l’audition et du language Troubles visuels Troubles du comportement Décès Outcomes for victims can be quite variable, depending on the severity of the injury. Some children with more minor injuries may recover with only mild sequelae, e.g. learning or behavioral problems. Children with more severe injuries may have more serious sequelae, including death.

44 Quels sont à votre avis les raisons de l’abus dans cette famille ?
Have the participants think about the risk factors present in this family, and how they may have resulted in abuse of this child.

45 Vignette 2 Maria – mère adolescente, Brésil
Trouvée sans connaissance, tentative de sucide possible 2 enfants de 3mois et 4 ans sales, affamés, problèmes de développement Elena – la petite fille de 4 ans se masturbe souvent – l’examen clinique est normal Maria a été abusée sexuellement dans l’enfance

46 Discussion Elena a-t-elle subi des abus sexuels ?
Dans quelle mesure l’examen clinique d’ Elena’s influence-t-il votre impression? Quelles ont été les conséquences de la maltraitance enfantine pour Maria Here are some of the questions that we will be discussing as we review what happened with Elena and Maria. 46

47 Discussion Elena et son frère ont-ils été négligés?
Quelle est la relation entre l’expérience de Maria et la négligence et l’abus sexuel envers ses enfants ? Here are some of the questions that we will be discussing as we review what happened with Elena and Maria. 47

48 Elena a-elle subi des sévices sexuels?

49 Abus sexuel des enfants
Participation d’un enfant à des activités sexuelles : Qu’il ne comprend pas complètement, Qu’il n’est pas capable d’accepter en connaissance de cause, Auxquelles sont niveau de développement ne le prépare pas, Qui viole les lois et les tabous de la société Les enfants peuvent être exploités sexuellement par un adulte ou un autre enfant don’t l’âge et le développement le placent dans une position de responsabilité, de pouvoir ou de confiance (From ISPCAN & WHO in, “Preventing Child Maltreatment”, 2006) This definition of Sexual Maltreatment of children is also from “Preventing Child Maltreatment” (WHO & ISPCAN 2006). Simply stated it says that the involvement of children in sexual activity of any sort, by an adult or older child in a position of trust or power, is maltreatment. This form of maltreatment is often a very difficult type to identify and difficult to prove. You should ask the audience if sexual maltreatment is an issue in their community. In some communities sexual maltreatment, whether involving children or adults, is such a taboo that it is not accepted as something that happens there. 49

50 Abus sexuel des enfants
Une agression souvent cachée Toutes formes d’activité sexuelle sont incluses, pas uniquement les rapports sexuels et les autres activités physiques Inclut la prostitution des enfants et l’exposition à la pornographie Sexual maltreatment not only includes the usual physical acts. It includes exposure to pornography and child prostitution. One point to make is that children are frequently reluctant to disclose sexual maltreatment and often not believed when they do. Studies indicate a child often has to tell several adults before someone listens to them. Even when they are believed most often there are no physical findings to prove a sexual contact took place. It is their word against that of the adult. The child may feel they have done something bad and be reluctant to disclose for this reason. 50

51 Caractéristiques de l’abuseur
Pas de profil type Beaucoup paraissent normaux, ont réussi et n’ont pas d’antécédents judiciaires La plupart sont des hommes Beaucoup sont des proches de l’enfant et souvent en position de confiance, d’autorité % sont des adolescents Beaucoup (pas tous) avaient eux-mêmes été victimes d’abus While sexual assault perpetrated by strangers often garners the most media attention, most abusers are people whom the victims know and often trust.

52 Les caractéristiques de l’enfant
Environ 85% sont des filles (cas connus du système) Tranches d’âge critiques : Garçons et filles – entre 5 et 7 ans Filles – 14 à 15 years Vulnérables, en manque d’affection Ask the audience why this statistic about the percentage of girls vs. boys may be inaccurate. (Answer – boys may be more reluctant to disclose, may feel greater sense of shame, may fear being labeled as homosexual). Interviews with imprisoned perpetrators of sexual abuse indicate that they often look for children (and their caregivers) who are vulnerable and needy, as they are easier targets.

53 Façons d’identifier ces enfants
Signes physiques : lésion ou infection Révélations de l’enfant – à un autre enfant, un parent, un soignant ou un adulte de confiance L’enfant agresse sexuellement un autre enfant L’enfant utilise des paroles sexuellement explicites, et son attitude ne correspond pas à un développement normal There are a number of ways that children who have been sexually abused may come to the attention of professionals. Physical injury and infection are the least common ways that children are identified – fewer than 5% of children who have been sexually abused have physical evidence of abuse. More often, a child’s statements or behavior lead someone to suspect abuse.

54 Un examen normal éllimine-t-il la possibilité qu’Elena ait subi des violences sexuelles ?
Based on the information from the previous slide, the audience should be aware that most children who have been sexually abused have normal exams. Ask them to think about why this may be the case.

55 L’examen médical - Résultats
“ C’est normal d’être normal ” Plus de 95% des enfants référés ont des examens normaux Pourquoi??? Les abus peuvent ne pas causer de lésions (comme les attouchements) Causer des blessures accroît le risque de dénonciation Les blessures guérissent souvent sans laisser de traces avant la révélation et l’évaluation médicale

56 Evaluation médicale – Ce qui n’est pas normal
Blessures génitales – Aiguës - déchirures, hématomes, morsures Sub-aiguës, chroniques – déchirures de l’hymen cicatrisées, cicatrices Infections transmises sexuellement Grossesse Preuves médico-légales – sperme, etc. As noted in the prior slide, it is unusual for children to have abnormal exams. Genital injury, either acute or chronic, indicates that some trauma has occurred. If there is a history of sexual abuse, or an absence of any history of accidental injury, sexual abuse is very likely. Sexually transmitted infections may be transmitted perinatally, or may be from consensual sex in a teenager. However, outside of these periods, sexually transmitted infections such as gonorrhea, chlamydia, and syphilis are highly likely to be from sexual abuse. Herpes is also likely to be from sexual abuse. However, transmission through non-sexual means (e.g. a child with an oral herpes lesion touching her mouth and then her genital area) is possible. HIV may also be transmitted through sexual abuse, however, infection via perinatal transmission, IV drug use, or blood transfusion must also be considered.

57 Comportement sexualisé des enfants
Causes possibles: Abus sexuel Difficultés de compréhension des normes sociales Ex : Enfant avec troubles du développement Curiosité/exploration sexuelle Exposition aux activités sexuelles explicites Témoin de ces activités au domicile, à la télé/ films Accès à la pornographie Par inadvertence, négligence ou abus des parents Sexualized behavior in a child may lead to caregiver suspicions about the possibility of sexual abuse. While sexually explicit behavior can be a manifestation of abuse, other causes should also be considered. Some sexualized behavior may be imitation of behavior to which a child is exposed. For example, a child may witness sexual activity in the home. When space is limited, all family members may share the same sleeping quarters, making this exposure difficult to avoid completely. Children living in nations at war may be inadvertently (or purposefully) exposed to sexual assault of women by enemy forces. In homes with televisions and computers with internet access, sexually explicit material is pervasive, and easy to find. At times, exposure to sexually explicit activities or material may be completely inadvertent (e.g. a child unexpectedly entering a room where adults are having sex or viewing sexually explicit media). It is also possible that an adult is viewing explicit material or engaging in explicit activity without regard to the child’s presence. This behavior should be considered neglectful. Finally, an adult may expose a child to sexually explicit material as part of a victim grooming process. Young children, particularly in the preschool years, are curious about their own bodies, as well as those of the opposite sex. Looking, touching, and asking about genitalia may reflect this curiosity. Children may touch their genitals because it feels good, even though they have little or no understanding of sexuality. Children with developmental disabilities may have difficulty understanding societal norms, and may engage in sexual behavior such as masturbation because it feels good. These children may not understand that such behavior is not appropriate in public.

58 Comportement commun de 2 à 9 ans (normalement sans rapport avec un abus) Friedrich WN. Normative sexual behavior in chidren. Pediatrics ; 101:e9 Garçons 1) Se touche les parties sexuelles chez lui 2) Se touche les seins 3) Se tient trop près 4) Essaie de voir les gens quand ils sont nus 5) Se touche les parties sexuelles en publique 6) Se masturbe manuellement Girls 1) Se touche les parties sexuelles chez elle 2) Se touche les seins 3) Essaie de voir les gens quand ils sont nus 4) Se tient trop près Se masturbe manuellement Se touche les parties sexuelles en public The data on the next several slides are based on research conducted by William Friedrich and colleagues. Parents of children who had not (to the best of the parents’ knowledge) been sexually abused reported on the behavior of their children. This slide shows the most common behaviors of boys and girls age 2-9 years. Note that the common behaviors in boys and girls in this age group are very similar.

59 Comportement commun de 10 à 12 ans (normalement sans rapport avec un abus) Friedrich WN. Normative sexual behavior in chidren. Pediatrics ; 101:e9 Garçons 1) Très intéressé par le sexe opposé 2) Veux regarder la nudité à la télé 3) Essaie de regarder des images de nudité 4) En sait beaucoup sur la sexualité 5) Parle des actes sexuels 6) Se touche les parties sexuelles à la maison Filles Très intéressée par le sexe opposé En sait beaucoup sur la sexualité Veut regarder la nudité à la télé Se touche les parties sexuelles à la maison Parle des actes sexuels This slide shows Friedrich’s study results for children in the preteen years. Again, the behaviors of boys and girls are similar, but there is more variation in the frequency of behavior among boys and girls in this age group, compared to the younger children.

60 Comportement rare de 2 à 12 ans (plus susceptible d’être lié à l’abus)
Place la bouche sur les parties sexuelles Demande à accomplir des actes sexuels Se masturbe avec des objets Enfonce des objets dans l’anus ou le vagin 5) Imite le rapport sexuel Emet des sons sexuels Essaie le baiser « profond » Déshabille les autres Demande à regarder des émissions télé explicites 10) Imite le comportement sexuel avec des poupées This slide also shows data from Friedrich’s research. However, these are the behaviors that were least commonly reported by parents. It is important to note that these behaviors, while uncommon, do not automatically indicate abuse. However, they are red (or pink) flags that should trigger additional assessment of the child’s safety and potential inappropriate exposures.

61 Comportements inquiétants
Un intérêt excessif pour la sexualité et des connaissances dépassant un développement normal Comportement inapproprié en dépit de mise en garde Comportement sexuel/exploration/coercition avec des enfants beaucoup plus jeunes ou plus âgés Blessures infligées à ses parties génitales ou celles des autres Comportement dérangeant aux toilettes Dessine des images où les parties génitales prédominent Contacts sexuels avec des animaux These behaviors are worrisome, and should prompt additional assessment.

62 Quelles ont été les conséquences de l’abus sexuel sur Maria ?

63 Impact de l’abus sexuel – La santé physique
A court terme Lésions aiguës MST A long terme: Problèmes gastro-intestinaux (côlon irritable) Douleurs chroniques (maux de tête, mal de dos, douleurs abdominales, pelviennes, ) Obésité, incapacité à bien se développer Somatisation Long term cohort studies and retrospective studies have shown a variety of impacts of CSA on adult health, both physical….

64 Impact de l’abus sexuel – Santé mentale
Problèmes de comportement – repli sur soi, indiscipline, délinquence Dépression Syndrome post-traumatique & autres troubles anxieux Toxicomanie Troubles de l’alimentation – anorexie, boulimie Echec scolaire Manque de confiance en soi, difficultés relationnelles And mental..

65 Elena et son frère ont-ils été négligés ?
Ask the audience whether Elena and her brother have been neglected. Remember that when found, Elena and her brother were dirty and hungry. They both appeared to have developmental delays.

66 Définition de la négligence envers l’enfant
Il y a négligence lorsque les besoins fondamentaux de l’enfant ne sont pas satisfaits ce qui entraîne un préjudice réel ou potentiel. Parmi les besoins fondamentaux : Nourriture - Vêtements Surveillance - Protection Soins médicaux - Education Amour et réconfort - Foyer Rather than blaming a caregiver for what they fail to do, many experts advocate for using a child-centered definition, described above. Review the definition, then have the group come up with a list of basic needs. Sometimes the entire responsibility can be ascribed to a single individual (or set of parents). Often, however, the situation is more complicated, and the responsibility for ensuring children’s basic needs lies in many hands, including health care providers, schools, and government. It appears clear that Elena and her brother were not receiving adequate food. Their developmental delays may indicate inadequate maternal bonding and nurturance. Maria may have attempted suicide and was found unconscious. Therefore Elena and her brother were not receiving adequate supervision. 66

67 Quel est le rapport entre les expériences de Maria et la négligence et les abus sexuels dont ses enfants sont victimes ? Ask the audience to think about which long-term effects Maria may have suffered, and how they may relate to the sexual abuse and neglect of Elena. For example, as a result of her own sexual abuse, Maria may be dealing with depression and PTSD. These conditions may make it difficult for her to meet the basic needs of her children. They may also make it difficult for Maria to take steps to keep her children safe from abuse and exploitation. In addition, Maria may suffer from low self esteem and difficulty forming healthy relationships. She may therefore choose partners who take advantage of her and her children. Finally, her partner may have targeted Maria and her children because of the children’s neediness, and Maria’s inability to protect them.

68 A retenir Tous les types de maltraitance augmentent avec certains facteurs de risque sociaux, en particulier la pauvreté L’abus sexuel est le moins lié La négligence est la plus liée Tous les types d’abus se retrouvent dans chaque groupe ethnique, social et économique

69 A retenir aussi Les allégations fausses sont rares
Les fausses dénégations sont fréquentes Les enfants abusés sexuellement deviennent souvent des témoins non coopératifs Fugueurs Enfants des rues “Délinquents”

70 A retenir Négligence : incapacité à répondre aux besoins fondamentaux de l’enfant (ses droits) Emotionnels Nutritionnels Abri Sécurité Santé Education

71 A retenir La négligence peut paraître bénigne C’est faux
Elle peut avoir des conséquences graves: Physiques: ex : problèmes de croissance, ingestions, décès Cognitives: ex : retard de développement, difficultés d’apprentissage Santé mentale: ex : problèmes émotionnels et comportementaux Sociaux: Délinquence juvénile et criminalité

72 Vignette 3 Homme d’un certain âge : Chine
Maux physiques et psychosomatiques Tabagisme et alcoolisme Battu dans son enfance Témoin de violence domestique Coupé toutes relations avec “mentor” Isolation sociale

73 Discussion Quelles “expériences défavorables de l’enfance” pouvez-vous reconnaître ou soupçonner ? Ce qui selon vous a pu se passer entre Lao Zhang et son mentor ? Y a-t-il eu abus sexuel ? Ask the audience, “Which of Lao Zhang’s experiences growing up might be considered adverse childhood experiences?” and “What other childhood events might be considered adverse childhood experiences?” Abuse and neglect should definitely be considered adverse childhood experiences (sometimes called ACEs). Witnessing domestic violence could also be considered an ACE (and many experts would also consider this to be child maltreatment). Other ACEs include death of a parent, natural disasters such as earthquakes or floods, war, or famine.

74 Discussion Quelles conséquences dans le comportement de Lao Zhang peuvent-elles être liées aux expériences de son enfance ? Quelles symptômes médicaux sont présents ou potentiels chez un patient comme Lao Zhang? Ask the audience to think about possible behavioral, medical, and mental health consequences of ACEs. 74

75 Impact de la maltraitance sur les enfants
Chaque enfant est touché – dans une mesure variable Plusieurs facteurs determinent l’impact : Type de maltraitance Personnalité de l’enfant Facteurs de protection Les conséquences peuvent être : Physiques Psychologiques Comportementales Sociétales In this section we will look at the impact of child maltreatment on children. This slide notes the important point that every child is affected by maltreatment. However, it recognizes the degree of the impact is variable dependant on the type and intensity of the abuse and the presence of protective factors. Ask the audience, “What are some examples of these consequences?” 75

76 Conséquences Blessures Fractures, brûlures, lésion des organes internes, lacérations, blessure à la tête Développement cérébral compromis Handicaps à court et à long terme Décès Some of the consequences, such as those associated with Physical Maltreatment are more obvious. Broken bones, lacerations and other physical injuries are easily identified. Longer term effects such as impaired brain development secondary to head injury may not be obvious initially but cause life long difficulty for the child who was injured. 76

77 Risque de cardiopathie ischémique par nombre d’expériences défavorables dans l’enfance
This slide looks specifically at how increasing ACE scores influence the odds of ischemic heart disease in adults. The authors controlled for medical and psychosocial risk factors, as these can also contribute to ischemic heart disease. 77

78 Conséquences psychologiques
Fréquentes Conséquences possibles: Problèmes immédiats d’isolation, de peur et de dfficulté à faire confiance Problèmes permanents de dépression, de manque de confiance en soi, de difficultés relationnelles Développement cognitif appauvri Children may develop both short-term and long-term psychological consequences from maltreatment. Some examples are listed in this slide. More details follow in subsequent slides. 78

79 Risque de suicide en fonction des expériences de l’enfance
Child maltreatment can lead to long-term mental health consequences. This data is also from the ACE study. In this study, adults with 4 or more adverse childhood experiences had 12 x the odds of suicide compared to adults with no adverse childhood experiences. 79

80 A retenir Plusieurs personnes âgées ont pu être victimes d’abus qu’elles ne considèrent pas comme tels ou qu’elles ne veulent pas discuter Ceci est particulièrement vrai de l’abus sexuel chez les garçons Etre témoin de la violence domestique peut avoir des conséquences graves pour les enfants

81 A retenir “Des expériences défavorables dans l’enfance” peuvent avoir des conséquences à long terme sur la santé Problèmes de santé (ex: maladie cardiaque) Problèmes de santé mentale (ex: dépression, tendance suicidaire) Vulnérabilité due au stress, à l’isolation sociale?

82 Vignette 4 Fillette de 6 ans A l’âge de 7 mois : Protégée
Fracture symptomatique du fémur Anciennes et récentes fractures des côtes “Lésions métaphysaires classiques” Protégée Famille traitée Rendue à sa famille

83 Discussion Questions Ce qui peut avoir causé les multiples fractures de Palwasha ? Ce qui s’est peut-être passé pour Palwasha lorsqu’on l’a séparée de sa famille ? Quels services pourraient aider Palwasha et sa famille?

84 Quelles peuvent être les causes des multiples fractures de Palwasha ?
Seems impossible to answer most of these. 84

85 Diagnostic différentiel des fractures des os longs
Maltraitance Non-infligée (blessure accidentelle) Problèmes médicaux qui augmentent le risque des fractures Ostéogénèse imparfaite Rachitisme While abuse is the most common cause of fractures in children this young, other causes need to be considered. Severe accidental injury can cause one or more fractures, however, this should be clear from the history. Some medical disorders can also cause easy fractures in young children, and should also be considered. Osteogenesis imperfecta is a disorder of collagen synthesis that can lead to easy fractures. There are several different forms of this disorder. The more severe forms should be obvious because of bone abnormalities present at birth. The less severe forms may not be obvious. Some additional traits that may be seen in osteogenesis imperfecta are blue sclerae, hearing loss (or family history of hearing loss), dentinogenesis imperfecta (teeth that easily break and decay), and family history of easy and frequent fractures. Rickets is a bone disease that results from inadequate vitamin D stores. Risk factors for rickets include dark skin, limited sun exposure, and inadequate vitamin D intake from breast milk or formula. The bones of children with rickets may show tenderness, rachitic rosary (bumps along the ribs), frontal bossing (prominence of the forehead), and thickening of the wrists and ankles. This condition can be identified and distinguished from abuse through laboratory testing. 85

86 Fractures des os longs Faible spécificité de maltraitance
SAUF CHEZ LES NOURRISSONS (AVANT L’AGE DU DEPLACEMENT) Fracture oblique ou spirale : non-spécifique Indique une force de torsion Long bone fractures are very common, and are more often the result of accidental injury than the are from abuse. The exception to this rule is in infants. Their lack of mobility makes it unlikely that they will injure themselves. There is a common misconception that spiral fractures are very specific for abuse. However, recent clinical and biomechanical studies have shown that accidental spiral fractures can occur. The spiral appearance indicates only that a torsional or twisting force caused the fracture. The spiral appearance does not indicate whether the injury is abusive or not.

87 Fractures des os longs – Fémur
Fractures accidentelles communes : Lorsque l’enfant court et tombe surtout dans un mouvement de torsion, Chute où le pied fait pivot Fractures du fémur très évocatrices de l’abus chez les bébés qui ne marchent pas encore In ambulatory (walking) children, femur fractures occur commonly in the two instances noted above.

88 Fractures des os longs – Humérus
Fracture diaphysaire Considérer l’âge de l’enfant & le récit de la blessure Fracture Supracondylaire Chute sur le coude Généralt pas infligée Abus plus probable chez le nourrisson As with the femur, fractures of the humerus are more often accidental than inflicted. However, in non-mobile children, abuse is much more likelly. A common accidental humeral fracture is the supracondylar fracture. This is a fracture of the distal humerus that is often the result of a fall onto the elbow.

89 Fractures des os longs – Tibia
Fracture des tout-petits Fracture oblique, non déplacée du tibia distal Récit d’un traumatisme absent ou léger Chez les enfants qui commencent à se déplacer ou à marcher NON-INFLIGEE A common accidental tibia fracture is the toddler’s fracture, described above.

90 Fractures des os longs – Lésion métaphysaire classique (CML)
Fracture en coin ou anse de seau selon l’angle Mécanisme : soit torsion ou force d’arrachement de l’extrémité soit forces d’accélération/ décélération lors d’un secouement TRES SPECIFIQUES A L’ABUS The classic metaphyseal lesion is seen in infants, at the metaphysis. Depending of the angle of the x-ray, it can have the appearance of a corner fracture (left-sided images) or a bucket handle fracture (right sided images). These fractures are highly specific for abuse in infants. They typically occur from twisting or pulling of an extremity, or from acceleration/deceleration forces that can occur during shaking.

91 RESUME – DIAGNOSTIC Spécificité des fractures
HAUTE MOYENNE BASSE CML (lésions métaphysaires) Fr. multiples surtout bilatérales Nouvel os sous-périosté Côtes Fr. D’âges différents Clavicule Scapula Décollement épiphysaire Diaphyse des os longs Apophyse épineuse Vertèbres Fracture linéaire du crâne Sternum Doigts/orteils Fr. craniales complexes Kleinman, PK. Diagnostic Imaging of Child Abuse, 2nd ed. St Louis, MO: Mosby, Inc P 9. This slide shows a summary of the specificity of various fractures for physical abuse. Among the fractures with a high specificity of abuse, we have already discussed rib fractures and classic metaphyseal fractures. Fractures of the scapula, spinous process and sternum are uncommon under any circumstances, and require a significant amount of force. In the absence of a history of severe injury, such as a motor vehicle crash, these fractures are diagnostic for abuse.

92 Ce qui s’est peut-être passé pour Palwasha lorsqu’on l’a retirée de sa famille ?
The answer to this question depends on the systems and resources available in Palwasha’s community. She may have been placed in foster care. If extended family was available to serve as a resource, she may have been placed in kinship care. Ideally, Palwasha’s parents (or the person responsible for her injuries) would receive services such as parenting education and anger management. An ideal system would also assess Palwasha’s family for maltreatment risk factors such as parental depression, intimate partner violence, substance abuse, etc. If Palwasha had siblings, they would also be assessed for possible maltreatment. Finally, Palwasha would be provided with trauma-focused counseling to prevent long-term mental health sequelae. 92

93 Discussion Quel système existe dans votre communauté pour protéger les enfants maltraités ? Comment pouvez-vous activer ce système? Quels services existent dans votre communauté pour soigner les enfants maltraités, les membres de leur famille qui ne les maltraitent pas et ceux qui les maltraitent ? These questions are intended to generate discussion among participants. Every country, state, and/or region has a different system for addressing child abuse and neglect. And all have different resources available to help families in which maltreatment has occurred. Participants can explain the processes in their own region, and discuss what components work well, and what could be improved.

94 A retenir: Démarche pour aider les enfants maltraités
Savoir reconnaître la maltraitance Arrêter l’abus et prévenir de futurs épisodes Traiter les conséquences médicales ET émotionelles Soutenir la famille – la rendre plus sûre OU Trouver un autre foyer plus sûr

95 A retenir De nombreux enfants maltraités souffrent de problèmes à vie Cependant… De nombreux enfants maltraités réussissent dans la vie Children are incredibly resilient. Many children have protective factors such as strong social support or self-efficacy that help protect them from long term negative outcomes

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97 A retenir Comment la protection est-elle assurée dans votre système légal/social ? Que pouvez-vous faire pour l’améliorer ? Quel traitement est-il disponible pour les enfants maltraités et leur famille ? Comment peut-on en améliorer l’accès ?

98 A retenir Jusqu’à 1/3 des cas de traumatisme infligé à la tête ne sont pas décelés à la première visite 27% sont maltraités de nouveau 40% présentent des complications 7% décèdent 98

99 A retenir L’abus sexuel se reconnaît : Aux lésions
Aux infections sexuellement transmises Au récit de l’enfant Aux changements Au trouble du stress post-traumatique (PTSD) 99

100 > 90% des examens physiques sont normaux
A retenir > 90% des examens physiques sont normaux Attouchements sexuels Sexe oral et anal Lésions cicatrisées Variation anatomique 100

101 A retenir Nombreuses conséquences tardives de l’abus :
PTSD, dépression, suicide Indiscipline, problèmes scolaires, toxicomanie Activité sexuelle prématurée, grossesse, MST, VIH 101

102 Discussion Quelles sont jusqu’à présent les conséquences de la négligence pour les enfants de Maria? Quels facteurs sociaux, familiaux et environnementaux ont-ils contribué à cette situation? 102

103 Discussion Quels droits légaux Maria a-t-elle de rester avec ses enfants ? Quels droits et quelles responsabilités Paulo a-t-il envers ses enfants en ce qui concerne l’aide financière, le soutien et les visites ?

104 A retenir Droits et responsabilités de la famille?
Maria Paulo Reste de la famille Capacité du système social à se substituer à la famille ou à l’aider? 104