INTRODUCTION
Worldwide, the problem of child maltreatment is still a widespread and heartbreaking one. It comes in different forms, including neglect and abuse, thus endangering the health and development of such children. Every kind of this word represents a specific variety of physical, sexual, and emotional abuse; however, most commonly, it refers to neglect, which brings specific negative results concerning physical, emotional, and social growth, among others. Among other types of abused child syndrome (also known as Silverman syndrome, Cafey- Kempe syndrome, traumatic parent-child stress syndrome, A. Tardieu syndrome, non-accidental trauma, and abused child syndrome), such acts can include physical assaults, rape, forced prostitution, and other types of aggression against children within the family or outside the home. It is well known that physical aggression against children takes various forms, such as beating, whipping, slapping, hitting the head, and, in this case, extreme malnutrition. Despite numerous initiatives to create awareness and also to put preventive measures into place, it stands that child abuse still has far-reaching effects on individuals, families, and neighbours.
Recently, public sensitivity to recognising and responding to child abuse has increased. Paediatricians, in particular, play a key role in recognising signs and symptoms of abuse, conducting thorough assessments, and promoting the safety and well-being of vulnerable children. Early detection and intervention are key to mitigating the negative consequences of abuse and facilitating the treatment and recovery of affected children [1]. One consequence can be complex post-traumatic stress disorder (C-PTSD; or complex post-traumatic stress disorder), a form of post-traumatic stress disorder (PTSD) resulting from prolonged exposure to traumatic experiences, particularly those involving interpersonal violence. C-PTSD is particularly relevant in the context of abused child syndrome as it often has deep-rooted psychological effects in children who are victims of ongoing abuse and neglect [2]. This article aims to provide a comprehensive overview of abused child syndrome, including its prevalence, risk factors, clinical manifestations, diagnostic considerations, and treatment methods. By presenting a case report of this patient and reviewing the relevant literature, we aim to clarify the challenges of diagnosing and treating this syndrome, and to emphasise the importance of a multidisciplinary approach to this complex issue.
CASE DESCRIPTION
Our patient circulated between wards and visited specialists for somatic reasons before receiving a proper diagnosis. He recounted what happened at home, which he described in detail during his third hospitalisation. How could it happen that a patient with such a history went unnoticed? Once again, we emphasise paying close attention to a child’s low self-esteem, irritability, outbursts of anger, and self-aggressive behaviour as a form of experiencing violence. A 12-year-old male patient comes from a non-formal relationship and has no knowledge of his biological father’s existence; also, he has a stepbrother. The boy’s mother has a degree in pedagogy. She used to work as a teacher but has not returned to work since the birth of her second child. The medical history shows that she experienced physical violence from her parents. The boy’s stepfather is unemployed and also completed higher education.
First hospitalisation in the allergy, gastroenterology, and child nutrition ward
A 9-year-old male patient appeared for the first time in the Paediatric Hospital with significant weight and growth deficiency and with features of cachexia. On admission, he weighed 17.98 kg and measured 125 cm. He had a history of abdominal pain, bloating, vomiting, and eating foods not intended for consumption. He had features of acute pancreatitis with a mild course. The complete blood cell counts with differential were without abnormalities. There were all negative microbiological cultures. Cardiology consultation: Systolic murmur over the heart. ECG results: Sinus tachycardia, steady 120/min. Trace of fluid in the pericardial sac. Endocrinology consultation: On examination, TSH, FT4, and FT3 levels were consistent with the diagnosis of low triiodothyronine cachexia syndrome. The result of the gastroscopy showed the oesophagus in the hypopharyngeal region with a few white exudative lesions; otherwise, the oesophagus was macroscopically unchanged. The oesophagus was functional, and the gastric mucosa was macroscopically unchanged. Pylorus was unobstructed; pylorus and extra-pyloric part of duodenum – macroscopically unchanged; villous structure seen. Chest X-ray and USG without changes. MRI scan of the head revealed a pineal cyst of 10 mm in diameter. On the MRI of the abdomen, there was free fluid in the peritoneal cavity, in the right flank, in the left iliac fossa and rectovesical recess. The layer width was up to 10 mm. A small amount of fluid was detected around the liver and spleen.
Information obtained from a telephone conversation with the mother: From an early age, he has had problems controlling his behaviour and emotions (outbursts of crying and screaming, especially when something did not go his way). He has been self-aggressive and aggressive towards children in kindergarten. According to his mother, his social development is unchallenged at present, and there were no eating disorders in the early years. In connection with behavioural disorders, he was under the psychological care of a psychological and pedagogical clinic. In the first grade, he was homeschooled. In the second grade, went to a public school. Then, disturbing behaviours appeared, including overeating, secondary abdominal pains, vomiting, and eating inedible things (e.g., lipstick or mouldy sandwiches stolen from a classmate). Parents themselves introduced a system of meal supervision for fear of gastrointestinal complaints. According to the mother, despite the maintenance of a steady diet, weight loss was observed, and the parents decided to start diagnostics in this direction.
Psychiatric consultation: The patient reports feeling comfortable in the unit. He ate larger portions at home due to hunger. As he explains, curiosity was the reason for trying inedible things, but he denies eating inedible things in his medical history. He reported that, due to his gluttony, he ate meals only under parental supervision at the appointed time. Furthermore, he was stressed by having to eat in small portions; however, he accepted the dietary restrictions, saying, “Because of my illness, so that I won’t feel bad, so that my pancreas will be healthy”. He does not want to upset his parents and be punished. At home, “sometimes” he is stressed and controls his behaviour because he does not want to be punished. When he is disobedient and eats too much food, he has to sit in a room and is not allowed to do anything. However, after a while, he explains that he feels safe at home, enjoys spending time with his parents, and speaks positively about them. He speaks very maturely about the family and the family rules. He enjoys going to school and says he would like to hang out with his classmates at home, but he is not allowed to because his parents are afraid that he might use social media.
On admission to the ward, the patient was very apprehensive, inquiring about his behavioural assessment and whether he was following the instructions in the ward, as he would like to give his mother the best news about his well-being and behaviour. At discharge, he weighed 24.9 kg and measured 125 cm. During his four-day pass, he lost 1.5 kg. According to the primary care clinic, he weighed 21 kg at the age of five. In the meantime, between the age of five and the current hospitalisation, growth inhibition was noted with a significant reduction in the child’s height centile position.
Second hospitalisation in the paediatrics, diabetology, endocrinology, and nephrology ward
Two months later, the patient was hospitalised for renewed weight loss and an expanded diagnosis of growth deficiency and hypoglycaemia. On admission, the boy’s general condition was fairly good. Physical examination revealed poorly developed subcutaneous adipose tissue, weight and height deficiency, enlarged abdominal circumference, and slender upper and lower limbs. In addition, laboratory tests showed anaemia and a very low HbA1c value. During three weeks of hospitalisation under a quantitatively restricted hospital diet, the boy’s weight increased to 29 kg. He did not require special nutritional management, and no significant gastrointestinal complaints or disorders were observed after the dietary restrictions were lifted. Potential hormonal causes of weight deficiency were ruled out. Subsequently, in the assessment of the endocrinologist, after the child’s nutritional status was normalised, there was a marked improvement in the rate of growth, pointing to extreme malnutrition as the cause of early growth retardation.
Information obtained during the meeting with the patient’s mother: The patient’s mother points to her son’s emotional and behavioural difficulties since he was about 3 years old. According to the mother, normal behaviour was initially observed in new environments, but over time, rebellion, anger, irritability, aggression, and self-aggression appeared. Similar behaviours occur at home when boundaries are set, when the patient’s expectations are not met, or when he disagrees with the content of the messages directed to him. From the age of three, the patient remained under specialised care, including speech therapy, social skills training, and sensory integration. At that time, she also observed initial selective eating. Therefore, according to the mother, dietary modification was applied due to increased appetite and following neurological recommendations.
Psychiatric consultation: Spontaneously reveals low self-esteem. He keeps repeating that he is stupid and bad because he made mistakes with his homework and has such a bad character that he beats children in kindergarten. Currently, he is self-aggressive (he beats himself on the head and his body). He confirmed Pica in the past and is ashamed of it.
Psychiatric re-consultation: The patient, at times weeping during the examination due to the declared sense of guilt, claims to have failed. He is lying on the floor in a corner, where he explains his remorse over watching a cartoon and eating food he was treated to by a friend. He indicates that he has feelings of guilt towards his parents for not living up to their expectations. Furthermore, he reports that, in connection with his naughty behaviour, he was punished by qualitative food restrictions, orders to do extra homework, and bans on playing at home. When he talks about these punishments, he is upset and gives negative evaluations of his behaviour. He reports difficulties in controlling his food intake and says he sometimes gets hungry and cannot stop eating. Necessary family intervention was recommended. Psychiatric hospitalisation was planned for consideration if behavioural and emotional symptoms and eating problems persist, as indicated by the history observed within the home environment.
The hospital received a court order to place the patient in foster care. In the presence of the patient’s orderly, attending physician, psychologist, and psychiatrist, the situation was explained, and support was provided. The patient received the information emotionally, was agitated, screamed, cried, was uncooperative at times, but gradually calmed down and the effectiveness of behavioural interventions was observed. Therapeutic management in the ward was applied. Currently, the patient does not require psychiatric hospitalisation. There are no indications for pharmacotherapy.
Hospitalisation in psychiatric hospital for children
The patient’s hospitalisation on the ward was related to the need to diagnose the increased aggressive and self-aggressive behaviours he began to display in the foster family he was placed in due to suspected physical and psychological abuse and neglect by his biological mother and her partner. When he was asked how he understood the reason for his admission to the psychiatric ward, he said, “I’m here because I’m traumatised, because I lost my family.” However, during his stay on the ward, the patient told how his parents had set up cameras in his room to control his behaviour. His quality meals were restricted (instead of a full dinner, he was given oatmeal with water). He hungrily ate things that were not edible, e.g., lipstick, a bath ball, a mouldy roll brought from a schoolmate, or stale food taken from other students’ backpacks. Once, he left home and went to a gas station where he told the employees that he was hungry. The police were called. He was also ordered to do extra homework and was forbidden to play. When he misbehaved, he was handcuffed to the bed or radiator, which was explained by the fear of damaging furniture because of his aggression.
He speaks badly only about himself; he is distrustful, fears something, and periodically tries to isolate himself. He constantly seeks confirmation that what he says is true. He is afraid of men and directly says that he was beaten, punished, locked in a dark room, and starved. At the same time, he treats these situations as normal and has no sense of being harmed. He says that, “In the past, children were beaten; they had to work, study, and be punished; they had no right to pleasure.” He declares that parents make only good decisions; they are the most important. When he was younger, he could decide on the type of punishment, e.g., whether he wanted to be chained to his bed or stay in his room all day. If parents observed on the cameras an improvement in his behaviour, they allowed him to sit on the bed. He was disciplined (spanked) with both a hand and a belt. He admits that it hurt. Additionally, he claims that through punishment, he learned respect.
In particularly difficult situations, he begins to self-harm, hitting his head against the wall or against the floor, threatening to gouge out his eyes, eating the wadding from his toys, scratching, biting, beating, and behaving aggressively towards others and other patients.
Since his discharge from the ward, the boy has remained under constant psychiatric and psychotherapeutic care at the local children’s mental health clinic. Recently, outpatient doses of medication were increased. At the time of admission, he was receiving Aripiprazole and Sertraline.
Follow-up
The patient was again admitted on an emergency basis, brought in by the emergency room because of aggressive behaviour at school. The medical history revealed that, under the influence of conflict in the peer group, he physically attacked a schoolgirl, then fled the classroom, was caught by a teacher, and was taken to the psychologist’s office, where he began to utter suicidal thoughts. In an objectively difficult family situation, there are currently proceedings in court against the mother and her partner, who are in custody. The boy was in foster care. After the foster parents and dissolution of the foster family, he was placed in the care of his maternal grandfather and his partner, with whom he has a good relationship. During the current hospitalisation, the court finally appointed the grandfather as the child’s legal guardian. The case against the boy’s mother has not yet been completed. The patient also maintains contact with his maternal grandmother and has a younger brother who has been placed in the orphanage.
On admission, the patient confirmed that he had uttered suicidal thoughts and tendencies, was negative about the hospitalisation, initially tried to force the guardian not to allow him to stay, stomped his feet, and was agitated, vulgar and verbally aggressive, after which he calmed down on his own. He studies well at school, likes his teachers and classmates, and cares about being liked and noticed in class. The boy’s foster mother and grandfather were consulted, and the circumstances of the adoption were discussed. According to the reports of the caregivers, since the change of residence, the boy’s aggressive behaviour has increased; he has become more irritable, explosive, oppositional, verbally aggressive, and less often physically aggressive towards caregivers. The boy tries to calm down and apologises for his behaviour. At school, he has a strong need for approval and is very sensitive to criticism. His classmates teased him, and this became the cause of conflict in the peer group. In difficult situations, he often accuses his caregivers of not being loved by them and that they are strangers to him. He later regrets his behaviour and calls himself a “thug”. The boy knows about the arrest of his mother and her partner, but in conversations, he rarely inquires about them and returns to traumatic memories. Together with his foster mother, he visited his younger brother, about whom he is worried. Because of the deterioration of the boy’s functioning in the ward, initially, a decision was made to increase the doses of the drugs used so far, but as this did not have the intended effect, a decision was made to discontinue the preparations of Aripiprazole and Sertraline and include Sulpiride. As a result of this procedure and the continuation of behavioural and therapeutic interventions, a gradual improvement in the boy’s mental state and functioning was observed. Due to optimal improvement in mental status, the patient was discharged without mood disorders, psychotic symptoms, and suicidal thoughts and intentions. Further psychotherapy, regular medication and a stable and safe care environment were indicated.
CONCLUSIONS
Abused child syndrome is a serious problem resulting from physical, emotional, or sexual abuse and neglect by a caregiver. The syndrome is characterised by a variety of symptoms, including constant visits to the hospital, accompanied by multiple injuries at various stages of healing, as well as developmental delays [3]. However, in our case, the patient had limited quality meals and was mentally abused. The boy has traits of Stockholm syndrome due to the positive feelings directed towards his abusers, not noticing wrongs, justifying the aggressor, and sharing the abusers’ views that he is bad and worthless, so he must be punished. He is grateful for the temporary absence of violence, such as being able to use the restroom and eat a meal or he could be confined to bed and that he could sit and not lie down. Then, he had the opportunity to read a story, which was a significant reward for him. The violence used by the boy’s parents caused psychological control by making him feel afraid and threatened, which destroyed his sense of self-esteem and dignity. They made the boy emotionally dependent on themselves in such a way that his thoughts and feelings as a victim depended on what the perpetrators were doing to him. The violence against the boy, due to its repetitive, continuous, and prolonged nature exposed him to multiple psychological injuries, which could result in a complex post-traumatic stress disorder in future [5].
Health professionals should play a significant role in identifying and reporting such suspected cases as early intervention can prevent further harm and expedite treatment. Any doctor who examines a child if he or she suspects abuse becomes the child’s first advocate. They are obliged to notify the police if they examine a child in whom they suspected non-accidental injury. The child’s future and even their life will depend on how we react and whether we notify the appropriate authorities. It is also not uncommon for them to require psychiatric drug treatment to alleviate the effects of the traumatic experience.
Features of a child experiencing violence:
