Abused, abused and neglected child syndrome

'Syndrome of an abused, abused and neglected child (CAN syndrome = Child abuse and neglect) can be defined as a set of adverse symptoms in various areas of the child's condition, development and his position in society and at the same time in the family. It mainly arises from intentional harm to a child, which is most often caused by the child's closest caregivers, mainly parents. The extreme form of CAN is the death of a child.

The term developed gradually from the 1950s. In the 90s of the last century, in Czech terminology, it was translated as the syndrome of an abused, abused and neglected child. According to the definition from that time, it is "any non-accidental behavior of parents or other adults that is rejected and unacceptable in the given society and that damages the physical, mental and social condition and development of the child, or will cause his death." A child is mistreated/abused/neglected if an adult "treats him/her in a way that is considered unacceptable in a given society at that time" (according to the "International Society for Prevention of Cruelty to Children, ISPCC'').

There is no corresponding disease code in ICD-10 (International Classification of Diseases, Revision 10) for CAN syndrome, but these conditions can be classified using codes from group T74 Maltreatment syndromes (S-T codes Injury, poisoning and some other consequences of external causes) and Y06 (Neglect and abandonment) - Y07 (Other ill-treatment). In some cases, code Z91.8 - Abuse, neglect in personal history (other specified risk factors in personal history) is also relevant not classified elsewhere). CAN belongs to the syndromes also referred to as victimization syndromes (victims of crimes). In ICD-11, it is also possible to classify the syndrome under code QE52.0 (child-caregiver relationship problem).

In European countries, about '4-5% of children are abused and abused (and this is probably only the "tip of the iceberg"). Boys are generally abused as often as girls, the proportion of girls is higher in the case of sexual abuse. First-born children and physically or mentally handicapped children are at higher risk of abuse. Children under the age of 2 are most often affected by severe forms of abuse. It is proven that parents of abused children have a similar experience from their childhood.

Experience with emotional abuse was declared by 15.6% of respondents, with physical abuse by 18%, with sexual abuse by 9.7% and with neglect by 37.2% of respondents. 24.5% of people had a single trauma, 23.8% had multiple trauma.

Child abuse is a 'criminal offense. In the criminal law, it is defined as "Abusing a person in charge" or "Abusing a person living in a shared apartment or house". Failure to report or prevent the crime of abuse of a trusted person is a crime. Notification of suspected abuse of a trusted person must be submitted to the police of the Czech Republic or the relevant public prosecutor.

Abuse

 * Physical abuse' - defined as physical harm to a child or failure to prevent harm or suffering to a child, including intentional poisoning or suffocation of a child, where there is certain knowledge or reasonable suspicion that the injury was caused or was not knowingly prevented.
 * Physical abuse according to WHO:
 * any blow of any intensity with any object or hand to the child's head;
 * any blow of any intensity with any object on other parts of the child's body;
 * a blow by the hand other than to the head, if this blow leaves more serious marks than a temporary reddening of the skin.


 * Typical signs of physical abuse:
 * hematomas of various ages (in 90% of abused children),
 * alopecia caused by hair pulling,
 * torn earlobe,
 * repeated fractures (chip fractura – at the ends of long bones, caused by excessive pulling, jerking, twisting),
 * spot burns with a cigarette or candle, extensive burns,
 * shaken infant syndrome, concussion and spinal cord concussion,
 * multiple internal organ injuries .*Emotional abuse - includes stimuli that have a serious negative effect on the child's emotional development. Emotional abuse can take the form of verbal attacks or rejection of the child, exposing the child to violence or serious conflicts at home, forced isolation, restraining the child, creating a situation where the child almost always feels fear, which can also cause emotional harm.
 * Examples: underestimating the child, name-calling, constant criticism, ignoring the child, disrespecting the child's privacy, mocking, humiliating, praising other people's children.
 * Manifestations: depressive mood, child's pity, eating disorders, excessive anxiety, apathy, gratuitous aggression; difficulty establishing contacts with peers, but good communication with adults, even abnormal friendliness with doctors and nursing staff ("hunger for petting"). Deterioration of school performance, sociopathic phenomena (drug addiction, gambling, sexual promiscuity, prostitution).

Sexual Abuse
Inappropriate exposure of the child to sexual contact, activity and behavior. It includes any sexual touching, intercourse or exploitation by anyone to whom a child has been entrusted or by anyone who abuses a child. Such a person can be a parent, relative, friend, professional or voluntary worker or a stranger. It is difficult to detect and prove .*'Non-touch - abuse where there is no physical contact (showing/playing pornography to a child).
 * Contact - there is physical contact, for example caressing of breasts and genitals, sexual intercourse oral and anal.
 * Warning signs: persistent vaginal discharge, repeated cystitis, urethritis, fissures, rags, hematomas and swelling of the genitals and anus, abdominal pain, bedwetting, etc.
 * Consequences: depression, suicidal behavior, alcohol and drug abuse, eating disorders, psychosomatic problems, problems in establishing partner relationships, low self-esteem, problems in social communication, premature initiation of sexual life, promiscuity, etc.

Neglect
It can be defined as a lack of care causing serious damage to the child's development or endangerment.


 * Physical - failure to satisfy the child's basic physical needs (e.g. insufficient nutrition, clothing, shelter, health care).
 * Emotional - failure to satisfy emotional needs (affection and sense of belonging).
 * Upbringing and education - making it impossible for a child to get an adequate education (resulting in falling behind and systemic abuse).
 * Warning signs: growth and development disorders, retardation or unevenness of psychomotor development, withdrawal symptoms, increased morbidity and mortality, insufficient social skills, passivity, withdrawal, indifference, emotional flatness, behavioral disorders, dependent behavior, sociopathological behavior, substitute emotional bonds, insufficient cultivation of behavior etc .===Bullying===


 * From the French chicané = malicious harassment, abuse, torment, persecution.
 * Relatively common form of psychological or physical abuse.
 * It most often takes place on a horizontal plane - in a group of school children, between siblings, residents of children's homes, etc.; in the vertical line it usually appears in the form of abuse of power.

Systemic abuse (secondary humiliation)
It is caused by a system that was established to help and protect children and their families. Such abuse is, for example:


 * undergoing unsparing and unnecessary medical examinations causing trauma (Münchhausen syndrome by proxy or Münchhausen by proxy syndrome),
 * anxiety caused by excessive contact with the judicial system,
 * denial of the right to information,
 * denial of the right to be heard,
 * unauthorized separation from parents.

Shaken Baby Syndrome
Shaken baby syndrome (shaken baby syndrome) is a set of symptoms caused by aggressive shaking of the infant. The person holds the infant firmly by the torso or arms while the head moves from sharp flexion to violent hyperextension. It is part of CAN. It is typically manifested by serial fractures of the ribs or humerus, and also includes the typical triad of CNS damage:

There are risk factors that make CAN syndrome more likely to occur.
 * 1) sheath subdural or subarachnoid hemorrhage,
 * 2) acute encephalopathy, swelling or diffuse axonal injury of the brain,
 * 3) retinal hemorrhage .==Risk factors for CAN syndrome==
 * From the parents - single and very young mothers; originally unwanted child; alcoholic or drug-addicted parents; parents who were depressed, abused or abused in childhood.
 * From the side of the child - disability; hyperactivity; prematurity and long separation after birth.
 * From the side of the environment - discrimination, e.g. due to ethnic minority; poverty and social isolation; separating children.

Physical abuse
Manifestations of child abuse:


 * hematomas on the body - especially on the torso, back, buttocks, arms and face;
 * swelling on the face and elsewhere on the body;
 * burns, multiple minor burns;
 * fractures – especially of skull bones, multiple rib fractures, separation of epiphyses and fractures that do not have a "willow twig" character;
 * lacerations and abrasions;
 * teeth marks, traces of beating with a belt, fingerprints after a blow;
 * injuries of different ages, etc.
 * A change in the child's behavior


 * the child does not wish to contact the parents;
 * manifestation of aggression and emotional lability;
 * trying to escape or fear of returning;
 * startle reactions to touch or approach;
 * the child covers his body even in warm weather;
 * increased obedience to parents or other legal representatives.

=== Warning signs ===


 * Lack of injury history;
 * Anamnesis not corresponding to the nature of the injury;
 * Anamnesis of injuries not appropriate for the child's age;
 * Presence of other injuries (including older ones);
 * Contradiction in the testimony of the child and the parent regarding the mechanism of injury;
 * Delay in seeking medical care;
 * Search for emergency services;
 * Children with medical disabilities

Sexual Abuse

 * Physical features:


 * pain, itching;
 * abrasions or bleeding from the genitals or anus;
 * occurrence of sexually transmitted disease;
 * IMC, genital discharge of unknown cause;
 * psychosomatic problems;
 * pain when walking and sitting in the area of ​​the anus or genitals.


 * A change in the child's behavior


 * sudden changes in behavior without a clear cause;
 * fear of a certain person;
 * run away from home;
 * self-harm, suicide;
 * use of drugs and other addictive substances;
 * anorexia, bulimia;
 * etc.

Mental abuse

 * Physical features


 * disproportionate growth or development;
 * speech defects;
 * delayed somatic or psychological development.


 * Changes in the child's behavior*compulsive or neurotic habits - eg rocking on a chair, wrapping hair around a finger;
 * feeling afraid of making mistakes;
 * self-harm;
 * inability to accept praise;
 * low self-esteem;
 * the child does not want to contact the parents;
 * problems joining the game;
 * excessive need for recognition, requires increased attention.

Neglect

 * Physical features:


 * starvation, weight loss and underweight;
 * dirty clothing and diapers;
 * dirt on the skin and behind the nails, odor;
 * lice, scabies;
 * inappropriate clothing due to the weather;
 * neglect of medical care – untreated diseases.

Changes in the child's behavior:


 * fatigue;
 * insufficient school attendance;
 * few friends;
 * child left alone and unsupervised;
 * compulsive stealing, rummaging through trash.

Procedure for suspected CAN

 * A precise record in the documentation about the communication between the parents and the child;
 * accurate record of clinical findings;
 * history taking and examination preferably in the presence of a witness - another medical professional;
 * always hospitalization of the child, even though the nature of the injury or disability does not require it;
 * examination by other experts (surgeon, gynecologist, psychologist, psychiatrist) - however, be careful to protect the child from secondary victimization - the goal is to help the child, not to harm him more;
 * immediate reporting to the social and legal child protection authorities of the territorial administration.

If the parents refuse hospitalization, the child's social and legal protection authorities must be informed, and in the case of serious concerns about the child's health or life, the police.

In case of suspicion of Münchhausen syndrome by proxy, we prefer non-invasive investigations and try to accept the child for observation and examination without the presence of the mother .ICD-11 indicates admission to care due to suspected CAN with code QA04.5

Therapy
Therapeutic work is carried out in a wide scope ranging from one-time ``crisis intervention (connected with diagnostics) through short-term individual, group or family therapy'' to a long-term form of psychotherapy, when the need for several months of care. An important component of therapy is also the form of 'sociotherapy, which we understand as field work in the form of contact with the family in its natural environment. In the practice of a general practitioner for children and adolescents, therapy is governed by the recommendations of specialist clinics and the social status of the child who is in the biological family or in substitute family care or in institutional care.

Prevention of CAN syndrome in the practice of a general practitioner

 * 1) 'Primary prevention of CAN syndrome requires: informing the public about the syndrome, cooperation with the municipality and its self-government, and cooperation with trusted non-governmental organizations. Primary prevention of CAN syndrome means a conscious and targeted focus on registered children from at-risk families.
 * 2) Secondary prevention depends on early diagnosis of CAN syndrome and cooperation between paediatricians, educators, psychologists and social workers.
 * 3) Tertiary prevention includes the resocialization of the injured child and his family using a multidisciplinary team.

Exploring the issue of CAN
CAN is a problem for which therapy requires interdisciplinary collaboration. In the fall of 2022, the Ministry of Health of the Czech Republic issued methodological measures "Procedure of general practitioners for children and adolescents in case of suspected abused, abused and neglected child (CAN syndrome)"

The issue is addressed at the global level by the organization "International Society for Prevention of Child Abuse and Neglect", which also publishes the specialist journal "Child Abuse & Neglect"

Related Articles

 * Münchausen syndrome by proxy • Sexual abuse • Pedophilia
 * Child's needs and rights • Family dysfunction • Caring for human needs • Substitute family care