2. Definition

3. Reports of Child Abuse In
Malaysia
Statistics from the Department of Social Welfare
The complications of Child Abuse Will Be Presented At The End Of
Presentation.

4. Child Abuse
(Classification)
Mohd Syafiq Bin Shahbudin
06-06-102

5. Neonaticide
Definition:
• It is killing of a premature or full term baby
within 24hours after birth.
• This case rarely in developed country. It is done
usually by young single uneducated mother by
act of commission or omission.

6. Cultural aspect:
• The Chinese, as late as the 20th century,
dispatched newborn daughters because they
were unable to transmit the family name.
Causes:
1) forbidden intercourse of unmarried young girl.
2) been raped and lead to unwanted child from
the assailant.

7. Infanticide
Definition:
• It is killing of newly born, live born infant within
12 months after birth.
Etiology:
• The mother with maternal psychosis (especially
puerperal depression) is almost always the
perpetrator.

8. Euthanasia
Definition:
• It is killing of a handicapped (physical, mental
or both) child usually under 3 years by a
parent.
Perpretrator:
• The mother is usually the maker.

9. Causes :
• low economic status of the parents that can’t
afford to maintenance their handicapped
child.
• no support from government and public to
help unlucky parents like an association to
assist parents by giving free consultation,
equipments to facilitate handicapped child.
• poor mental state of the parents.
• unfaithful parents.

10. Syndrome of repetitive physical child
abuse
• It occurs more frequently in families of lower
socioeconomic standard.
• The child is usually in the age group 6 weeks –
5 years and experiencing pleomorphic assaults
often with increase in severity and frequency

11. Causes:
1) Great stress -
Many people who commit physical abuse
were abused themselves as children.
As a result, they often do not realize that
abuse is inapproriate discipline.
2) Poor impulse control -
This will prevents them from thinking about
the result from their actions.

12. Statistic:
• The rate of child abuse is fairly high.
The most common form is neglect

13. By: Muhamad Ariff
Bin Mohd Randzan
06-6-109

14. (5) Child neglect:
It may take many forms:
 Physical neglect (food, hygiene,
clothes).
 Safety neglect.
 Medical neglect.
 Educational neglect.
 Emotional neglect.

15. (6) Murder-suicide:
Often whole family is killed usually in
one accident.
(7) Murder-homicide:
The great majority of victims are girls
after sexual assaults.

16. (8) Sexual abuse:
1- Assaultive: producing injury or severe
emotional trauma.
2- Non-assaultive: causing no or little
physical trauma & less emotional stress.

17. (9) Emotional abuse:
It is persistent rejection or coldness of
parents or guardian toward a child
which affect his behavior &
development.

19. Omar Mokhtar Bin Che Azani
06-6-67

20. Risk Factors
 Parental factors
 Family factors
 Child factors
 Environmental factors

21. Parental Factors
 Personality characteristics and
psychological well-being
 History of childhood abuse
 Substance abuse
 Attitudes and knowledge
 Age (young parents 15-20 years)

22. Personality characteristics and
psychological well-being
 No consistent set of characteristics or
personality traits has been associated with
abusive parents.
 Some characteristics frequently identified
in those who are physically abusive or
neglectful include:
 low self-esteem,
 poor impulse control
 depression
 anxiety
 antisocial behavior

23. History of childhood abuse
 A parent's childhood history plays a large
part in how he or she may behave as a
parent.
 Individuals with poor parental role models
or those who did not have their own needs
met may find it very difficult to meet the
needs of their children.
 There are individuals who have not been
abused as children who become abusive,
as well as individuals who have been
abused as children and do not
subsequently abuse their own children.

24. Substance abuse
 Substance abuse can interfere with a
parent's mental functioning, judgment,
inhibitions, and protective capacity.

25. Attitudes and knowledge
 Negative attitudes and attributions about a
child's behavior and inaccurate knowledge
about child development may play a
contributing role in child maltreatment.
 For example, some studies have found that
mothers who physically abuse their
children have both more negative and
higher than normal expectations of their
children, as well as less understanding of
appropriate development of the children.

26. Age
 Mothers who were younger at the birth
of their child exhibited higher rates of
child abuse than did older mothers.
 Other contributing factors, such as lower
economic status, lack of social support,
and high stress levels may influence the
link between younger childbirth—
particularly teenage parenthood—and
child abuse.

27. Family Factors
 Family structure
 Marital conflict and domestic violence
 Stress
 Parent-child interaction

28. Family structure
 Children living with single parents may be at higher
risk of experiencing physical and sexual abuse and
neglect than children living with two biological
parents.
 Single parent households are substantially more
likely to have incomes below the poverty line.
 Lower income, the increased stress associated with
the sole burden of family responsibilities, and fewer
supports are thought to contribute to the risk of
single parents maltreating their children
 In addition, studies have found that compared to
similar non-neglecting families, neglectful families
tend to have more children or greater numbers of
people living in the household

29. Marital conflict and domestic
violence
 30 to 60 % of families where spouse abuse
takes place, child maltreatment also occurs.
 Children in violent homes may witness
parental violence, may be victims of physical
abuse themselves, and may be neglected by
parents who are focused on their partners or
unresponsive to their children due to their own
fears.
 A child who witnesses parental violence is at
risk for also being maltreated, but, even if the
child is not maltreated, he or she may
experience harmful emotional consequences
from witnessing the parental violence.

30. Stress
 Stress is also thought to play a
significant role in family functioning.
 Physical abuse has been associated
with stressful life events, parenting
stress, and emotional distress in various
studies.

31. Parent-child interaction
 Families involved in child abuse seldom recognize or
reward their child's positive behaviors, while having
strong responses to their child's negative behaviors.
 Abusive parents have been found to be less
supportive, affectionate, playful, and responsive with
their children than parents who do not abuse their
children.
 Research on maltreating parents, particularly
physically abusive mothers, found that these parents
were more likely to use harsh discipline strategies
and verbal aggression and less likely to use positive
parenting strategies.

32. Child Factors
 The abnormal or disable child
 The rejected child
 Other child characteristics

33. The abnormal or disable
child
 Children with physical, cognitive, and emotional disabilities
appear to experience higher rates of maltreatment than the
other children.
 In general, children who are perceived by their parents as
"different" or who have special needs including children with
disabilities, as well as children with chronic illnesses or children
with difficult temperaments may be at greater risk of abuse.
 The demands of caring for these children may overwhelm their
parents.
 Disruptions may occur in the bonding or attachment processes,
particularly if children are unresponsive to affection or if children
are separated by frequent hospitalizations.
 Children with disabilities also may be vulnerable to repeated
abuse because they may not understand that the abusive
behaviors are inappropriate, and they may be unable to escape
or defend themselves in abusive situations.

35. The rejected child
 This child may be unwanted sex or
pregnancy. This unwanted child usually will
be maltreat because the parent itself do not
want to have that child.
 For example, the mother who was raped
tend to abuse her child to show her anger
and revenge towards the rapist.
 The study shows that parent who want the
children will treat their child better than the
parent who have the child from the
unwanted sex or pregnancy.

36. Other child characteristics
 Some studies suggest that infants born
prematurely or with low birth-weight may
be at increased risk for maltreatment
 The relationship between low birth-weight
and maltreatment may be attributable to
higher maternal stress heightened by high
caregiver demands, but it also may be
related to poor parental education about
low birth-weight, lack of accessible prenatal
care, and other factors, such as substance
abuse or domestic violence.

37.  Child factors such as aggression, attention
deficits, difficult temperaments, and behavior
problems or the parental perceptions of such
problems have been associated with
increased risk for all types of child
maltreatment.
 These factors may contribute indirectly to child
maltreatment when interacting with certain
parental characteristics, such as poor coping
skills, poor ability to empathize with the child,
or difficulty controlling emotions.
 In addition, these same child characteristics
may be reinforced by the maltreatment.

38. Environmental Factors
 Poverty and unemployment
 Social isolation and social support
 Violent communities

39. Poverty and unemployment
 Poverty and unemployment show strong
associations with child maltreatment, particularly
neglect.
 Poverty particularly when interacting with other risk
factors such as depression, substance abuse, and
social isolation can increase the likelihood of
maltreatment.
 Low income creates greater family stress, which, in
turn, leads to higher chances of maltreatment.
 Parents with low incomes, despite good intentions,
may be unable to provide adequate care while
raising children in high-risk neighborhoods with
unsafe or crowded housing and inadequate daycare

40.  Some other characteristics may make
parents more likely to be both poor and
abusive
 For example, a parent may have a
substance abuse problem that impedes the
parent's ability to obtain and maintain a job,
which also may contribute to abusive
behavior
 Poor families may experience maltreatment
at rates similar to other families, but that
maltreatment in poor families is more
frequent

41. Social isolation and social
support
 Some studies indicate that compared to
other parents, parents who maltreat their
children report experiencing greater
isolation, more loneliness, and less
social support.
 Social isolation may contribute to
maltreatment because parents have less
material and emotional support, do not
have positive parenting role models.

42. Violent communities
 Children living in dangerous
neighborhoods have been found to be at
higher risk than children from safer
neighborhoods for severe neglect and
physical abuse, as well as child sexual
victimization.

43. THANK YOU FOR LISTENING

44. INVESTIGATIONS
IN A CASE OF
CHILD ABUSE
Ahmad Farhan Bin Mahabot
06-6-9

45. MEDICAL HISTORY
Conducting
Professional
Interviews
Good rapport Open-ended
Qs
General to
Child alone
specific
Confidentiali
ty

46. MEDICAL HISTORY
 Suggestive findings:
A history that does not match the nature or the
severity of the injury
 Vague parental accounts or accounts that
change during the interview
 Accusations that the child injured him/herself
intentionally
 Delay in seeking help
 Child dressed inappropriately for the situation

47. GENERAL SIGNS
 Emotional abuse
 Excessively withdrawn and fearful
 Anxious about doing something wrong
 Extremes in behaviour
 Lack of attachment with the parent/caregiver
 Acts inapproppriately adult or infantile

48. GENERAL SIGNS
 Physical abuse
 Unexplained injuries e.g. bruises, burns or cuts
 Certain pattern such marks from hand or belt
 Always watchful or ‘on alert’ for bad things
 Wears inapproppriate clothing to cover injuries
 Admitting to punishment that seems excessive

49. GENERAL SIGNS
 Child neglect
 Wears ill-fitting and filthy clothes
 Consistently bad hygiene
 Untreated ilness and physical injuries
 Left alone in unsafe environment
 Begs or steals food or money

50. GENERAL SIGNS
 Sexual abuse
 Trouble walking or sitting
 Starting to wet at bed and having nightmares
 Doesn’t want to change clothes in front of others
 Lustful act and seductive behaviour
 Medical conditions like STDs or pregnancy

51. THANK YOU

52. PHYSICAL EXAMINATION
& REGIONAL SIGNS
of child abuse.
Prepared by:
NOOR AZILA BINTI ABDULLAH
06-6-21

54. PHYSICAL EXAMINATION
Detailed documentation of concerning findings :
1. BODY DIAGRAM & PHOTOGRAPH
 Nutritional neglect, Fail to meet expected growth
 Photo of injuries
2. CLOTHING
 Signs of neglect (dirty, ill-fitting, stained, unwashed, bad
odour),
 Wearing clothes inappropriate to the weather (to cover
bruises)

55. 3. REGIONAL EXAMINATION & SIGNS
search for other signs that may indicate a non-traumatic cause of injury

56. REGIONAL SIGNS
 HEAD
 NECK
 EYES
 EAR
 MOUTH & LIPS
 CHEST
 ABDOMEN

57. ABUSIVE HEAD INJURIES
 This area is vulnerable to injury because of a child‟s small
stature.
 It may be the closest body part to an adult‟s hand or fist.
 It is where the crying, back talk, bad language, etc. is
emanating from.

58. GENERAL SIGNS OF HEAD
INJURY
Some children will present with clear signs of head injury.
They will either be :
 unconscious or
 show signs of brain injury (such as fitting, paralysis or
extreme irritability)
However, some children may present with less obvious
signs, such as:
 increased head circumference,
 poor feeding,
 excessive crying.

59. “SHAKEN BABY SYNDROME”
(CAFFEY‟S SYNDROME/
BATTERED CHILD
SYNDROME)
• Excessive violent shaking or
sudden impact to head
• Most commonly in children
less than 2 years of age.
• Characterized by retinal,
subdural and/or
subarachnoid hemorrhages
• May present with coma or
seizures without obvious
evidence of scalp trauma

60. Intracranial haemorrhage
occurs as a result of
severe angular
acceleration, deceleration
& direct impact as the
head strikes a solid
object.
The chest is compressed
resulting in rib fractures.
Arms & legs move about
in a whiplash movement
resulting in the typical
'corner' or 'bucket-
handle'-fractures in the
metaphyseal region.

61. LOCAL (PHYSICAL) SIGNS OF
HEAD INJURIES
 SCALP
 FACE
 EYE
 EAR
 MOUTH
 NECK

62. SKULL FRACTURES
Skull fractures are common
child abuse injuries, but
they are also common in
accidental trauma.
Patterns of skull fracture
that suggest child abuse
are: LEFT: eggshell fractures in a child who
died of cerebral injury after being thrown
of a height
• Multiple 'eggshell'
fractures RIGHT: skull fracture crossing suture in
• Occipital impression abused child
fractures
• Fractures crossing
sutures

63. Scalp Injuries
TRAUMATIC
SCALP BRUISES/SCAR ALOPECIA
SCALP LACERATION
(CUT WOUND)

64. Face injuries
SLAPPING MARKS
CUT WOUNDS & BRUISES
BRUISES & PETECHIAE

65. Black eye (Raccoon eye)

66. Ear injuries
Post-auricular bruising
Bite mark
Subgaleal hematoma & Fingernail prints

67. Fractured teeth as a
Mouth injuries result of a backhand blow
to the face.
Brusing on soft
palate from forced
oral sex.
Trauma from a
direct blow to the
child's mouth.
Torn frenulum
Tongue laceration --note that this child had no teeth
that could have caused this.

68. Neck injuries
Strangulation mark
Choking mark
Burn on side of the neck

69. CHEST INJURIES
EXTERNAL INJURIES RIB FRACTURES
Old posterior rib fractures very
indicative of non accidental trauma.
Skin of the chest showing  They are not evident on x-ray
“belt-marks” & bruises. in the acute stage, as little
displacement occurs.
 They are identified in the
healing stage as a result of
associated callus.

70. INTERNAL ORGAN
INJURIES
 Visceral injury is seen at
autopsy of young infants, but it
is rarely documented
radiologically in living victims
less than 1 year of age.
 The mortality rate is 50% due
to 'patients and doctors delay„ Common abdominal injuries in
-- children are brought to the abused children are:
hospital days after the injury,
when perforation already has • liver laceration
resulted in peritonitis and • duodenal perforation/
sepsis. hematoma
• pancreatic laceration.

71. VISCERAL INJURIES
Pancreatic laceration Liver laceration

72. VISCERAL INJURIES
A, A round, fading bruise over the right
lower abdominal wall. Note the marked
abdominal distention.
B, At surgery she was found to have
diffuse peritonitis, and two large rents
were discovered in the jejunal
mesentery.
C, A long segment, found to be necrotic
with a perforation, and adjacent bowel
that appeared nonviable were resected.

73. THANK YOU!

74. Student name : Mohammad Amin bin Khairudin
Student number : 06-5-86

75. Limbs :
 Bruises – around joints ( especially
wrist,forearm,upper arm,thighs and ankles ) from
gripping in order to swing or shake the infant
 Fractures – at any site in diaphysis , may be multiple
 Spiral fractures – indicate twisting injury
 Traction – Avulsion of parts of metaphysic and slipped
epiphysis
 Joint effusions

76. Bites :
Abuser bites, self- inflicted bites and other children
bites must be distinguished.
 Favorite sites : Arms,back of
hands,cheeks,shoulders,buttocks
 Shape : Two opposing semicircles with
abrasion,contusion,or both
 Size : Dental arch size determines whether it
is done by adult,child,or animal

77. Bite mark example

78. Burns :
1. Dry burns - Burns in unlikely sites e.g.
buttocks and perineum.Children
may be sat on hot plates,branded
with irons or hot metals.
- Cigarette burns on areas normally
covered by clothing usually multiple
and of different ages.
2. Scalds - Over hot bath water
- Deliberate pouring of hot water
- Dipping in hot liquid
Poisoning :
Occurs more commonly in baby sitters.The drugs used
more are antihistamines,cough mixtures and laxatives.

79. Scald example 1

80. Scald example 2

81. By Kamarul Azhar bin Mohamed
06-06-79

82.  For children younger than 2 years suspected
of having been physically abused, a skeletal
survey is recommended to rule out skeletal
injury.
 To evaluate for missed physical abuse and
unsuspected fractures
 Provide the diagnosis of abuse in 50% of the
children with positive skeletal survey results

83.  1.Long-bone injuries
◦ Direct blow /shear force
 2.Rib fractures
◦ Compressive force
 3.Head injuries
◦ Forceful shaking

84.  Fracture may cross the diaphysis in an
oblique or transverse plane
 Fracture may occur at metaphysis known as
classic metaphyseal lesion(corner/bucket
handle lesion)

85.  Highly specific and classic metaphyseal lesion
(CML) occurs when a torsional force is applied
to the immature primary spongiosa adjacent
to a cartilaginous growth plate.
 Fractures of the posterior rib, scapula,
spinous process, and sternum(bones which
are ordinarily difficult to break)
 Fractures in different stages/ages of healing
 Fractures are usually multiple

86.  multiple bilateral rib fractures of different
ages

87.  Useful in patients with:
◦ Head injury, especially with skull fractures
◦ Acute neurological findings
◦ Physical examination show retinal haemorrhage
◦ Visceral injuries and retroperitoneum haemorrhage
 Common findings in cases of abuse:
◦ Subdural especially interhemispheric and
subarachnoid hemorrhage
◦ Duodenal and proximal jejunum injuries

88. Subarachnoid hrg Subdural hrg

89.  CT scanning of the thorax(lung injury) and
abdomen(duodenal injury)

90.  CT scanning of the liver injury

91.  More sensitive to small subdural and
subarachnoid haemorrhages, contusions of
cortex and deep white matter lesions.
 Used when CT findings is confusing such as:
◦ for differentiating a hypoattenuating subdural
hematoma from cerebrospinal fluid (CSF)
◦ detecting small and chronic extra-axial fluid
collections.

92. Detect most commonly
brain parenchymal injuries
shear injury contusion
gray matter– edema
white matter
junction
corpus callosum
midbrain

93.  No role in the evaluation of acute abusive
injury.
 May be used:
◦ In unstable patients being examined in the
emergency department for initial screening for
visceral injuries and free fluid.
 Less sensitive than CT scanning

94.  assists in identifying new rib fractures and
subtle long bone fractures not apparent on
the skeletal survey especially at the
costovertebral junction

95.  Has high sensitivity and low specificity in
cases of child abuse.
 Correlation with x-ray is always necessary

97. Child Abuse
Complications Fine / Penalty
• Health and physical • Punishable under the Child
Act (2001) and the Penal
effects Code (revised 1997).
• Intellectual and cognitive • Offenders may be liable to
development a maximum fine of RM
50,000 ( about 100,000
• Emotional, psychological, EGP ) or up to 20 years
and behavioral imprisonment, or both
depending on the offence.
consequences • Offenders may also be
punished with whipping in
addition to the fine and/or
imprisonment

98. Health and physical
effects
• The immediate effects
of bruises, burns,
lacerations, and
broken bones
• Longer-term effects of
brain damage,
hemorrhages, and
permanent disabilities.

99. Intellectual and cognitive
development
• Evidence of lowered
intellectual and cognitive
functioning in abused
children as compared to
children who had not been
abused, and other studies
find no differences.
• Research has consistently
found that maltreatment
increases the risk of lower
academic achievement and
problematic school
performance. Abused and
neglected children in these
studies received lower
grades and test scores than
did no maltreated children.

100. Emotional, psychological, and
behavioral consequences
• Emotional and psychological
Consequences
o Low self-esteem
o Depression and anxiety
o Post-traumatic stress
disorder (PTSD)
o Attachment difficulties
o Eating disorders
o Poor peer relations
o Self-injurious behavior
(e.g., suicide attempts)
.

101. Emotional, psychological, and
behavioral consequences

102. Child Abuse
(Prevention)
Mohd Syafiq Bin Shahbudin
06-06-102

103. Prevention :
• Recognize the warning signs of abuse
• Have alcohol or drug problems
• Have a history of abuse or was abused as a
child
• Have emotional problems or mental illness
• Have high stress factors, including poverty
• Not look after the child's hygiene or care
• Not seem to love or have concern for the child

104. • Counseling or parenting classes may prevent
abuse when any of these factors are present.
Watchful guidance and support from the
extended family, friends, clergy, or other
supportive persons may prevent abuse or
allow early intervention in cases of abuse.

105. References
• http://emedicine.medscape.com/article/4071
44-overview
• http://emedicine.medscape.com/article/9156
64-overview
• Lectures of forensic medicine textbook by staff
members of department of forensic medicine
and clinical toxicology, faculty of medicine,
Alexandria University.