Child abuse - clinical investigation, management and nursing approach

Sammanfattning: The overall aim of this thesis is to describe how children suspected of being abused were taken care of in a large Children’s University hospital. Study I Aim: To evaluate clinical investigations for suspected child abuse in infants presenting to a Paediatric Emergency Department (ED) with certain primary complaints known to be associated with child abuse. Methods: All medical records of ED admissions that included at least one of the selected primary complaints and a record of a CT head scan having been performed were located in the hospital database. Forty seven medical records satisfied our inclusion criteria. Results: Eighty seven percent of the 47 children had a head injury as the initial diagnosis. Thirty eight percent of the children belonged to the age group 0-3 months. Of the children admitted to the ED due to a head injury, twenty two children (54%) had a history deemed to be suspicious for abuse while only one child had indeed been properly investigated for possible child abuse. Conclusion: Despite good reasons, only a small number of investigations of suspected child abuse were carried out in the Children’s hospital. The hospital staff had difficulties in properly recording whether there were any signs suspicious of child abuse. Study II Aim: To identify children diagnosed as victims of child abuse in a large Children’s University hospital during a four-year period, with focus on whether reports to social services were done. Methods: We studied retrospectively; all medical records of children assigned an ICD 10 code appropriate for child abuse. Results: We found 137 children diagnosed as victims of child abuse, out of which 42 were abused sexually while 95 where physically abused. According to the medical records, the medical staff reported only 55% of these cases to the social services. Conclusion: Efforts to improve knowledge of signs of child abuse is essential, as are intensified education concerning the laws requiring medical staff to report suspected child abuse and the proper procedures for such reporting. Study III Aim: The aim of this study is to identify children below 2 years of age who may have been physically abused by searching the medical records for reports of CT brain scans. Methods: The study group was identified using the computerized medical records database in the Children’s University Hospital. All CT head scan reports (n=1925) during a 8 year period were reviewed and we selected only those in which an intracranial haemorrhage was described. Results: The most common reason for admission to the ED was a fall from a low height (n=28). In 22/68 children (32%) the hospital staff filed a report to the social services. The neuroradiologist suggested child abuse as a possible explanation for the findings on the CT scan in 28 (41%) children. Of this subgroup 61 % (n=17) were investigated for child abuse and 15 (54%) of these children were reported to the social services. Conclusion: The neuroradiologist’s report is an indispensable part of the clinical investigation of possible child abuse. A mere description of the findings is not so useful. It is the opinion expressed by the neuroradiologist that the findings should lead to a further investigation of possible child abuse, that is important. Study IV Aim: The aim of this study was to identify nurse’s experiences in the clinical care of victims of child abuse. The objective was to assess how nurses could remain professional especially when the suspected perpetrator is a parent. Methods: Investigators used a qualitative design with a critical incident technique. Eleven nurses who cared for abused children and their parents in a tertiary care University children’s hospital were interviewed. Results: We highlighted three areas in the analysis of the interviews: Feelings of ambivalence, nurse’s professionalism and the nurse’s care strategies. The subjects expressed difficulties in maintaining a professional role in clinical encounters with the parents. The nurses experienced conflicts in their roles to deal with being both a police (a judicial function) and a nurse (a caring function). Conclusions: The nurses expressed that they had devised strategies to remain professional in the clinical encounter with abused children and their parents. To remain professional, education, counselling and experience was essential.

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