Dealing with child abuse

Paediatric trauma and child abuse by Sebastian van As and Sudeshni Naidoo

(Oxford University Press Southern Africa) R239,35

It is helpful to have a book dealing with child abuse authored by practitioners working in the South African context. Much of our literature on child abuse, in all its forms, and on the management of child abuse originates in developed countries, where the context, contributing factors, management procedures and especially resources are frequently very different.

The book focuses on the prevention and management of child abuse from a medical perspective and, therefore, relates mostly to the prevention and management of physical abuse. The problem of sexual abuse is dealt with somewhat superficially and the problems of emotional and psychological trauma are barely dealt with at all.

This is unfortunate, because once the initial crisis of physical injury is dealt with and prophylactic medical intervention occurs to prevent further physical consequences of the injury or violation, most children and families require psycho-social intervention to facilitate healing of the intrapersonal and interpersonal consequences of abuse.

The first part of the book, “Child trauma and abuse”, deals with the broad issues relating to child abuse and is probably of some value to all professionals and occupational groups who come across child abuse in the course of their work.

Chapter one has some useful statistics on child injuries and childhood deaths and emphasises the special vulnerability of children. It examines the extent of the problem of child abuse, the impact of childhood injury (somewhat cursorily dealt with), causal factors, gives an explanation of intentional and non-intentional injuries to children and discusses prevention.

The section on prevention, however, focuses mainly on the prevention of physical injury and neglects to a large extent the prevention of other forms of child abuse.

Other chapters in this section are:

  • “Violence and children in South Africa”. This chapter has some useful statistics that enable the reader to compare injury to children in South Africa with international figures. Once again there is a fairly lengthy section on prevention, the focus on physical injury.
  • “Post-traumatic stress disorder in children and adolescents.” This provides some clear and simple pointers to assist in the assessment and diagnosis of post-traumatic stress disorder, which differs in its presentation in children compared with adults. A brief section on treatment and management provides some helpful intervention, with the references at the end giving the reader access to more detailed information on management.
  • A chapter directed specifically at providing the nursing profession with basic management information.
  • A further chapter on child abuse, the major focus on physical and sexual abuse, with information on diagnosis and initial management. Again the focus is mainly on physical healthcare investigation and management. This chapter ends with two brief but valuable inputs one focuses on legal issues and the responsibility of the professional with regard to reporting and testifying in court and the second on the impact of working with abused children on the professional and emphasising the need for regular support and debriefing to prevent compassion fatigue and burnout.
  • Chapter seven, The role of non-medics in child abuse, is somewhat of a misnomer and should be titled in such a way that the necessity for professional intervention of other than medical occupations is recognised as integral to the holistic healing and management of the abused child and family. This chapter has value in that it clearly elucidates indicators of physical, sexual and emotional abuse as well as neglect, and describes the roles of the police, educators, social workers and others.
  • The chapter on medical-legal considerations is practical and useful in that it deals with some of the questions relating to consent for examinations of children, refusal by parents and caretakers for the medical professional to examine and treat, confidentiality as to records, forensic (court-related) issues and the role of the doctor as a witness in court. What this chapter does not include is the fact that trained forensic nurses are becoming increasingly acceptable as expert witnesses in cases of child abuse and sexual assault worldwide. It is important that their role be recognised.

Part two of the book has several chapters on early medical management of child injuries, pre-hospital care when a medical professional might treat a child at the scene of the accident or injury and mass casualty situations.

A second chapter in this section deals with the initial assessment and treatment of the child and contains descriptions of procedures that attempt to ensure the immediate preservation of life, followed by specific and technical chapters on airway management, shock and fluid management, emergency surgical procedures, radiological assessment of injuries and the management of pain and anxiety; the latter is often neglected when working with child victims of trauma. Two chapters on anaesthesia and blood transfusion for child victims follow.

Part three deals in detail with specific injuries that children might experience as a result of abuse and/or trauma, such as brain injury, cervical spine injuries, maxillo-facial and oral injuries, caustic injuries (usually caused by swallowing chemical substances), injuries caused by swallowing foreign objects, ear, nose and throat injuries, eye, chest, abdominal, vascular, orthopaedic, genital-urinary and gunshot injuries, as well as injuries caused by burns, bites and stings. This section ends with a chapter on the difficult issue of brain death and organ donation.

Although this final part of the book contains technical information, it does have value for those professionals working in the child abuse field, representing professions other than medical. As the introduction to this section states, “non medical readers…will benefit from the statistical and contextual information contained in some of these chapters” as well as from guidelines for first aid contained in some chapters for those who have first contact with the injured child.

This book will be most useful for the medical professional who has contact and responsibility for the medical care and protection of children injured through abuse and some value for professionals other than those in the medical profession, especially when working in a multidisciplinary team in a medical setting.

Joan van Niekerk is national coordinator of Childline South Africa

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