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Dealing with child abuse victims needs multi-sectoral co-ordination:  Study

07 Oct 2021

  • Forensic, Psychiatry, Probation and Child Care Services, Social Services, Labour, Education, and Police Departments, and JMOs offices should form links
By Ruwan Laknath Jayakody Lines of communication and linkages must be developed among the stakeholders providing services in the context of handling children who are victims of abuse in order to specially address systemic lapses with regard to referral and follow up in cases of child abuse. These recommendations were made by D.M.G. Fernando, D.H. Edussuriya, and K.M.P.L. Dayaratne (all attached to the Peradeniya University’s Medical Faculty’s Forensic Medicine Department) in a research article on “Repeated episodes of physical child abuse: Is the existing system on managing child abuse defective in Sri Lanka?” which was published in the Sri Lanka Journal of Forensic Medicine, Science and Law 1 (2) in January 2011. With regard to repeated child abuse or what B. Knight and P. Saukko’s Knight’s Forensic Pathology described as “child abuse syndrome”, it involves an infant or child suffering repetitive physical injuries inflicted by a parent or a guardian, in circumstances that are not accidental. Per A.A.D. Elkerdany and A.A. Buhalqa’s “Fatal physical child abuse in two children of a family”, physical abuse is found in approximately 70% of child abuse cases, with the nature of the abuse ranging from minor bruises to fatal haematomas where there is localised bleeding outside of the blood vessels. Fernando et al. reported a case where a child (over the course of 20 months) had been, in spite of a diagnosis made by paediatricians and judicial medical officers (JMOs) of physical child abuse, repeatedly released into the same hazardous environment, and which had resulted in the child being subjected to repeated abuse, in turn resulting in multiple hospital admissions with seven long bone fractures, multiple rib fractures, and other life threatening injuries. Case report A five-month-old baby girl was brought to the Nuwara Eliya District General Hospital by her parents, who were estate labourers, with swelling of the left arm and excessive crying. There was no history of fever, trauma, or of a fall. The weight at the time of admission was well below the third centile while the height was between the third and 10th centiles. On examination however, the child was found to be feverish and the left arm was swollen and deformed. The X-ray revealed a recent fracture of the mid shaft of the left humerus (the bone of the upper arm or forelimb, forming joints at the shoulder and the elbow) and healing fractures of the mid shaft of the ulna and the radius (the two bones that make up the forearm) of the same side. The baby was transferred to the Kandy Teaching Hospital (presently the Kandy National Teaching Hospital) for specialised orthopaedic (injuries and diseases of the musculoskeletal system) management. The JMO referred the baby to an eye surgeon, a neurosurgeon, and a radiologist. A diagnosis of physical child abuse or non-accidental injury was made and the Police and the Probation and Child Care Services Department were informed. Upon discharge however, the baby was sent home. Six months later, at the age of 11 months, the child was taken to the Peradeniya Teaching Hospital with swelling of the left-lower limb and reduced movements. There was no history of trauma. The X-ray revealed a recent spiral fracture in the mid shaft of the left femur (thighbone). The JMO was informed and a skeletal survey revealed multiple healing rib fractures and a transverse fracture (takes place when a bone breaks at a 90 degree angle to the long axis of the bone) with a callus (area of thickened skin) in the mid shaft of the right ulna. A diagnosis of physical child abuse was made for the second time and the Police was informed. Once again, the child was discharged, without further action. Nine months later, at the age of 20 months, the child was once again taken to the Peradeniya Teaching Hospital with focal fits (seizures which initially affect only one hemisphere of the brain) and swelling of the left thigh. On examination, she was found to be drowsy and had a spastic (abnormal muscle tightness due to prolonged muscle contraction) right-upper limb. The computed tomography (CT) scan of the brain revealed multiple haemorrhagic (excessive bleeding) infarcts (tissue death due to inadequate blood supply to the affected area). The child was referred to the Peradeniya University’s Medical Faculty’s Forensic Medicine Department and a skeletal survey revealed a recent fracture of the upper third of the left femur and evidence of previous fractures in different stages of healing as noted by H.M.L. Carty in “The radiological features of child abuse”. Additionally, a healed right tibial (the main bone of the lower leg, forming the shin) metaphyseal (an injury to the metaphysis which is the growing cartilage plate at each end of a long bone) fracture was detected. The baby was referred to an eye surgeon, a neurosurgeon, cardiologist, psychiatrist, and radiologist. Extensive investigations were conducted, including a dual-energy X-ray absorptiometry (DEXA) scan which is an imaging test that measures bone density or strength was done, per D.G. De Silva’s “Child abuse: A manual for medical officers in Sri Lanka”, in order to exclude pathological conditions. The mother and sibling were also investigated to exclude hereditary bone diseases. A diagnosis of physical child abuse was made for the third time and the Police was informed. At this juncture, a case conference organised by the Peradeniya University’s Medical Faculty’s Forensic Medicine Department and facilitated by the Society against Child Abuse and Neglect (SCAN, the brainchild of the Peradeniya University’s Medical Faculty’s Forensic Medicine Department and the Psychiatry Department) was held, comprised of representatives from the Probation and Child Care Services Department, Social Services Department, Labour Department, Education Department, and the Police was held and members of the SCAN, the child’s parents, the investigating Police officer, the estate medical assistant, the two crèche attendants, the paediatric consultants, the forensic medicine consultants, the radiology consultants, the community medicine consultants, the Senior Registrar in Paediatrics, and the academic staff of the Peradeniya University’s Medical Faculty’s Forensic Medicine Department. The mother, whilst denying any form of abuse at home, noted however that she keeps the baby in an estate nursery daycare centre, which is managed by two attendants who have 40 children in their charge, during the daytime when she is working. The crèche attendants claimed that the child had sustained no injuries whilst in their care. The estate medical assistant claimed that there had not been reports of similar cases in the estate since he commenced work there in January 2004, noting also that the four-year-old sibling of this child did not have any such notable injuries. At this stage, the participants, including the parents, unanimously agreed that the child should not be sent back to the same environment, and therefore, the child was sent to a home for her safety. One-and-a-half years later, the weight was above the third centile and the height was between the 10th and 25th centiles, showing an upward curve across the centile lines. Since admission, the child has not had any other fractures, significant injuries, or further hospital admissions. That said, both limbs on the right side were spastic with an increased tone, while the reflexes were exaggerated. Discussing the case, Fernando et al. elaborated that clinical acumen, skill, and diplomacy are all needed by a physician in the context of identifying and managing child abuse, as if such is not diagnosed, it may not only lead to the continuous suffering of an innocent child, but also result in a permanent handicap or worse, death. Therefore, diagnosis alone does not suffice, as the relevant authorities must take necessary action to prevent further harm from being inflicted on the child. According to Fernando et al., the reason for the repeated abuse suffered by this child, in spite of a correct diagnosis, was the lack of co-ordination between the doctors, the Police, and the Probation and Child Care Services Department. Fernando et al. further emphasised that even though many argue that the institutionalisation of an abused child results in further abuse, the release of children into unsafe environments may lead to permanent physical or psychological damage to the child, or even death. Hence, Fernando et al., added that even if a correct diagnosis is made and the relevant authorities are informed, it is still important to look at each child individually so as to decide and do what is in the best interest of a particular child. In this regard, Fernando et al. recommended that all Forensic Medicine Departments and offices of JMOs form such links with the various Departments associated with the care and protection of children. If you feel that you or someone you know may be dealing with a similar situation, the following institutions would assist you:

National Child Protection Authority helpline: 1929 Ministry of Child Development and Women’s Affairs helpline: 1938 Sri Lanka Police Child and Women Bureau: 011 244 4444 LEADS: 011 495 4111


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