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(BQ) Part 1 book Murtagh''s general practice presents the following contents: The basis of general practice, diagnostic perspective in general practice, problem solving in general practice, child and adolescent health.
general practice ctice Murtagh Prelims.indd i 22/10/10 2:21:55 PM To all our medical colleagues, past and present, who have provided the vast reservoir of knowledge from which the content of this book was made possible Murtagh Prelims.indd ii 22/10/10 2:21:55 PM fifth edition Murtagh Prelims.indd iii general practice 22/10/10 2:21:55 PM NOTICE Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete Readers are encouraged to confirm the information contained herein with other sources For example, and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this book is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs This fifth edition published 2011 First edition published 1994, Second edition published 1998, Third edition published 2003, Fourth edition published 2007 Text © 2011 John Murtagh Illustrations and design © 2011 McGraw-Hill Australia Pty Ltd Additional owners of copyright are acknowledged in on-page credits/on the acknowledgments page Every effort has been made to trace and acknowledge copyrighted material The authors and publishers tender their apologies should any infringement have occurred Reproduction and communication for educational purposes The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is the greater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that the institution (or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and been granted a licence For details of statutory educational and other copyright licences contact: Copyright Agency Limited, Level 15, 233 Castlereagh Street, Sydney NSW 2000 Telephone: (02) 9394 7600 Website: www.copyright com.au Reproduction and communication for other purposes Apart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of this publication may be reproduced, distributed or transmitted in any form or by any means, or stored in a database or retrieval system, without the written permission of McGraw-Hill Australia including, but not limited to, any network or other electronic storage Enquiries should be made to the publisher via www.mcgraw-hill.com.au or marked for the attention of the Permissions editor at the address below National Library of Australia Cataloguing-in-Publication Data: Author: Murtagh, John, 1936Title: General practice / John Murtagh Edition: 5th ed ISBN: 9780070285385 (hbk.) Notes: Includes index Bibliography Subjects: Family medicine Physicians (General practice) Dewey Number: 610 Published in Australia by McGraw-Hill Australia Pty Ltd Level 2, 82 Waterloo Road, North Ryde NSW 2113 Publisher: Elizabeth Walton Associate editor: Fiona Richardson Art director: Astred Hicks Cover design: Astred Hicks Cover and author photographs: Gerrit Fokkema Photography Internal design: David Rosemeyer Production editor: Michael McGrath Permissions editor: Haidi Bernhardt Copy editor: Rosemary Moore Illustrator: Alan Laver/Shelly Communications and John Murtagh Cartoonist: Chris Sorell Proofreader: Karen Jayne Indexer: Garry Cousins Typeset in Scala by Midland Typesetters, Australia Printed in China on 70 gsm matt art by iBook Printing Ltd 987654321 Murtagh Prelims.indd iv 22/10/10 2:21:55 PM The authors John Murtagh AM MBBS, MD, BSc, BEd, FRACGP, DipObstRCOG Emeritus Professor in General Practice, School of Primary Health, Monash University, Melbourne Professorial Fellow, Department of General Practice, University of Melbourne Adjunct Clinical Professor, Graduate School of Medicine, University of Notre Dame, Fremantle, Western Australia Guest Professor, Peking University Health Science Centre, Beijing J ohn Murtagh was a science master teaching chemistry, biology and physics in Victorian secondary schools when he was admitted to the first intake of the newly established Medical School at Monash University, graduating in 1966 Following a comprehensive postgraduate training program, which included surgical registrarship, he practised in partnership with his medical wife, Dr Jill Rosenblatt, for 10 years in the rural community of Neerim South, Victoria He was appointed Senior Lecturer (part-time) in the Department of Community Medicine at Monash University and eventually returned to Melbourne as a full-time Senior Lecturer He was appointed to a professorial chair in Community Medicine at Box Hill Hospital in 1988 and subsequently as chairman of the extended department and Emeritus Professor of General Practice in 1993 until retirement from this position in 2000 He now holds teaching positions as Professor in General Practice at Monash University, Adjunct Clinical Professor, University of Notre Dame and Professorial Fellow, University of Melbourne He combines these positions with part-time general practice, including a special interest in musculoskeletal medicine He achieved the Doctor of Medicine degree in 1988 for his thesis ‘The management of back pain in general practice’ He was appointed Associate Medical Editor of Australian Family Physician in 1980 and Medical Editor in 1986, a position held until 1995 In 1995 he was awarded the Member of the Order of Australia for services to medicine, particularly in the areas of medical education, research and publishing One of his numerous publications, Practice Tips, was named as the British Medical Association’s Best Primary Care Book Award in 2005 In the same year he was named as one of the most influential people in general practice by the publication Australian Doctor John Murtagh was awarded the inaugural David de Kretser medal from Monash University for his exceptional contribution to the Faculty of Medicine, Nursing and Health Sciences over a significant period of time Members of the Royal Australian College of General Practitioners may know that he was bestowed the honour of the namesake of the College library Today John Murtagh continues to enjoy active participation with the diverse spectrum of general practitioners—whether they are students or experienced practitioners, rural- or urban-based, local or international medical graduates, clinicians or researchers His vast experience with all of these groups has provided him with tremendous insights into their needs, which is reflected in the culminated experience and wisdom of John Murtagh’s General Practice v Murtagh Prelims.indd v 22/10/10 2:21:56 PM vi The authors Dr Jill Rosenblatt MBBS, FRACGP, DipObstRCOG, GradDipAppSci General Practitioner, Ashwood Medical Group Adjunct Senior Lecturer, School of Primary Health Care, Monash University, Melbourne J ill Rosenblatt graduated in medicine from the University of Melbourne in 1968 Following terms as a resident medical officer she entered rural practice in Neerim South, Victoria, in partnership with her husband John Murtagh She was responsible for inpatient hospital care in the Neerim District Bush Nursing Hospital and in the West Gippsland Base Hospital Her special interests were obstetrics, paediatrics and anaesthetics Jill Rosenblatt also has a special interest in Indigenous health since she lived at Koonibba Mission in South Australia, where her father was Superintendent After leaving rural life she came to Melbourne and joined the Ashwood Medical Group, where she continues to practice comprehensive general medicine and care of the elderly in particular She was appointed a Senior Lecturer in the Department of General Practice at Murtagh Prelims.indd vi Monash University in 1980 and a teacher in the GP registrar program She gained a Diploma of Sports Medicine (RACGP) in 1985 and a Graduate Diploma of Applied Science in Nutritional and Environmental Medicine from Swinburne University of Technology in 2001 Jill Rosenblatt brings a wealth of diverse experience to the compilation of this textbook This is based on 38 years of experience in rural and metropolitan general practice In addition she has served as clinical assistant to the Shepherd Foundation, the Menopause Clinics at Prince Henry’s Hospital and Box Hill Hospital and the Department of Anaesthetics at Prince Henry’s Hospital Jill has served as an examiner for the RACGP for 34 years and for the Australian Medical Council for 12 years She was awarded a life membership of the Royal Australian College of General Practitioners in 2010 22/10/10 2:21:56 PM Foreword I n 1960 a young schoolmaster, then teaching biology and chemistry in a secondary school in rural Victoria, decided to become a country doctor He was admitted to the first intake of students into the Medical School of the newly established Monash University and at the end of the six-year undergraduate medical course and subsequent intern and resident appointments his resolve to practise community medicine remained firm During his years of undergraduate and early postgraduate study Dr Murtagh continued to gather and record data relating to the diagnostic and therapeutic procedures and clinical skills he would require in solo country practice These records, subsequently greatly expanded, were to provide at least the foundation of this book Happily, after graduation, he married Dr Jill Rosenblatt, a young graduate from Melbourne University, who shared his vocational interests Subsequently they also shared the fulfilment of family life and the intellectual and emotional satisfaction of serving as doctors in a rural setting In the meantime the Royal Australian College of General Practitioners had established postgraduate training programs that had a significant influence on standards of professional practice At the same time Monash University established a Department of Community Medicine at one of its suburban teaching hospitals, under the Chairmanship of Professor Neil Carson and staffed by practitioners in the local community While in practice Dr Murtagh gained a Fellowship of the College through examination The College recognised his unique clinical, educational and communication skills and immediately commissioned him to prepare educational programs, especially the CHECK programs His outstanding expertise as a primary care physician led to his appointment as a senior lecturer in the University Department of Community Medicine The success of the initial academic development in Community Medicine at Monash University, and its influence on the clinical skills of its graduates as they relate to primary care, led to a University decision to establish a further Department of Community Medicine at another suburban teaching hospital in Melbourne It was considered by the University to be entirely appropriate that Dr Murtagh be invited to accept appointment as Professor and Head of that Department Four years later Professor Murtagh was appointed Head of the extended Department and the first Professor of General Practice at Monash University John Murtagh has now become a national and international authority on the content and teaching of primary care medicine As Medical Editor of Australian Family Physician from 1986 to 1995 he took that journal to the stage where it was the most widely read medical journal in Australia This textbook provides a distillate of the vast experience gained by a once-upon-a-time rural doctor whose career has embraced teaching from first to last, whose interest is ensuring that disease, whether minor or life-threatening, is recognised quickly, and whose concern is that strategies to match each contingency are well understood General Practice is the outcome of the vision of a schoolteacher of great talent who made a firm decision to become a country doctor; through this book his dream has become a reality for all who are privileged to practise medicine in a community setting It is most appropriate that Jill Rosenblatt, John’s partner in country practice has joined him as co-author of this fifth edition The first edition of this book, published in 1994, achieved remarkable success on both the national and international scene The second and third editions built on this initial success and in an extraordinary way the book became known as the ‘Bible of General Practice’ in Australia In addition to being widely used by practising doctors, it has become a popular and standard textbook in several medical schools and also in the teaching institutions for alternative health practitioners, such as chiropractic, naturopathy and osteopathy In particular, medical undergraduates and graduates struggling to learn English have found the book relatively comprehensible The fourth edition was updated and expanded, and retained the successful format of previous editions but with a more attractive and user-friendly format including clinical photographs and illustrations in colour John Murtagh’s works have been translated into Italian by McGraw-Hill Libri Italia s.r.l., Portuguese by McGraw-Hill Nova Iorque and Spanish by McGraw-Hill Interamericana Mexico, and into Chinese, Greek, Polish and Russian In 2009 John Murtagh’s General Practice was chosen by the Chinese Ministry of Health as the textbook to aid the development of general practice in China Its translation was completed later that year GC SCHOFIELD OBE, MD, ChB(NZ), DPhil(Oxon), FRACP, FRACMA, FAMA Professor of Anatomy, Monash University, 1961–77 Dean of Medicine, Monash University, 1977–88 vii Murtagh Prelims.indd vii 22/10/10 2:21:56 PM Contents The authors Foreword Acknowledgments Preface Making the most of your book Reviewers Normal values: worth knowing by heart Abbreviations v vii xii xiii xiv xviii xxi xxii Part The basis of general practice 1 10 11 12 13 14 15 16 17 18 19 The nature and content of general practice The family Consulting skills Communication skills Counselling skills Difficult, demanding and angry patients Health promotion and patient education The elderly patient Prevention in general practice Nutrition in healthand illness Palliative care Pain and its management Research and evidence-based medicine Travel medicine Tropical medicine and the returned traveller Laboratory investigations Inspection as a clinical skill A safe diagnostic strategy Genetic conditions 14 21 29 39 43 48 62 72 81 90 103 112 125 136 145 150 158 Part Diagnostic perspective in general practice 177 20 21 22 23 24 25 26 27 28 Depression Diabetes mellitus: diagnosis Drug problems Anaemia Thyroid and other endocrine disorders Spinal dysfunction Urinary tract infection Malignant disease HIV/AIDS—could it be HIV? 178 186 193 204 211 222 225 233 241 viii Murtagh Prelims.indd viii 22/10/10 2:21:56 PM Contents Murtagh Prelims.indd ix 29 30 31 32 33 34 Baffling viral and protozoal infections Baffling bacterial infections Infections of the central nervous system Chronic kidney failure Connective tissue disease and the vasculitides Neurological dilemmas 251 258 270 275 282 291 Part Problem solving in general practice 307 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Abdominal pain Arthritis Anorectal disorders Thoracic back pain Low back pain Bruising and bleeding Chest pain Constipation Cough Deafness and hearing loss Diarrhoea The disturbed patient Dizziness/vertigo Dyspepsia (indigestion) Dysphagia Dyspnoea The painful ear The red and tender eye Pain in the face Fever and chills Faints, fits and funny turns Haematemesis and melaena Headache Hoarseness Jaundice Nasal disorders Nausea and vomiting Neck lumps Neck pain Shoulder pain Pain in the arm and hand Hip, buttock and groin pain Pain in the leg The painful knee Pain in the foot and ankle Walking difficulty and leg swelling Palpitations Sleep disorders Sore mouth and tongue 308 329 351 359 373 394 403 423 434 449 458 474 491 500 510 514 526 539 554 564 573 581 584 601 604 620 629 634 638 651 663 679 691 708 727 744 751 764 773 ix 22/10/10 2:21:56 PM Common childhood infectious diseases (including skin eruptions) 889 Ecthyma is a deeper form of impetigo, usually on the legs and other covered areas Treatment If mild with small lesions and a limited area: • topical antiseptic cleansing with gentle removal of crusts, using antibacterial soap, saline chlorhexidine or povidone-iodine Then mupirocin (Bactroban), a small amount tds for 10 days Topical antibiotics other than mupirocin 2% (Bactroban) are not recommended.7 • other measures to minimise recurrence or transmission of bacteria:8 — daily bath with Oilatum Plus bath oil for 2–4 weeks — hot water wash for clothes, towels and linen for 2–4 weeks — regular hand washing If extensive and causing systemic symptoms:7 flucloxacillin/dicloxacillin 6.25 mg/kg up to adult dose (250 mg) (o) hourly for 10 days or cephalexin 6.25 mg/kg up to adult dose (250 mg) (o) hourly for 10 days (first choice) Boils (furunculosis) and carbuncles—same treatment as impetigo If Streptococcus pyogenes is confirmed use: benzathine penicillin IM or phenoxymethyl penicillin (orally)9 The child should be excluded from child-care settings until sores have healed fully Head lice Head lice is an infestation caused by the louse Pediculus humanus capitis (see Fig 84.11) The female louse lays eggs (or ‘nits’), which are glued to the hairs; they hatch within days, mature into adults in about 10 days and live for about a month Head lice spread from person to person by direct contact, such as sitting and working very close to one another They can also spread by the sharing of combs, brushes and headwear, especially within the family Children are the ones usually affected, but people of all ages and from all walks of life can be infested It is more common in overcrowded living conditions Resistance to the usual agents is becoming a problem Clinical features • • • • • Asymptomatic or itching of scalp White spots of nits can be mistaken for dandruff Unlike dandruff, the nits cannot be brushed off Diagnosis by finding lice (or ‘nits’) ‘Wet combing’ improves detection rate Murtagh - General Practice (5e) Part 4.indd 889 MPVTF FOMBSHFE Figure 84.11 Louse (enlarged) Treatment (topical)10 pyrethrins/piperonyl foam or shampoo (e.g Lyban foam)—leave minimum 20 minutes or permethrin 1%—leave minimum 20 minutes or Maldison 0.5% (leave hours) 84 Method Massage well into wet hair, then wash off thoroughly Repeat treatment at 7–10 days Treat household child contacts at the same time Remove nits after first treatment with hair conditioner and fine-tooth comb Note: The hair does not have to be cut short All members of the family must be treated if lice or nits are found on inspection Wash clothing, towels and sheets after treatment using a normal machine wash or hot soapy water The hot cycle of a dryer is also effective for killing lice on bedding School exclusion should not be necessary after proper treatment For eyelash involvement, apply petrolatum bd for days and then pluck off remaining nits Follow up with combing hair wetted by conditioner weekly Resistant head lice Repeat treatment using another insecticide A US RCT showed that 1% permethrin plus a 10 day course of cotrimoxazole was the best treatment for resistant head lice.11 Handy tips for removing nits • Combing with a hair conditioner is useful to remove the nits or • Apply a 1:1 mixture of water and vinegar, leave 15 minutes, then comb with a fine-toothed comb Prevention • Apply conditioner to dry hair once a week and then comb it out with a fine comb 22/10/10 2:42:56 PM 890 Part Four Child and adolescent health Patient education resources REFERENCES Hand-out sheets from Murtagh’s Patient Education 5th edition: • Chicken Pox (Varicella), page 22 • Hand, Foot and Mouth Disease, page 120 • Head Lice, page 141 • Herpes Simplex (Cold Sores), page 135 • Impetigo, page 40 • Measles, page 43 • Mumps, page 44 • Roseola, page 49 • Rubella, page 50 • Slapped Cheek Disease, page 53 • Whooping Cough (Pertussis), page 154 Jarman R A word about aspirin in children Australian Paediatric Review, 1991; 1(6): 2 Efron D Paediatric Handbook (5th edn) Melbourne: Blackwell Science, 1996: 69 Robinson MJ Practical Paediatrics (5th edn) Melbourne: Churchill Livingstone, 2003: 340–2 Mansfield F Erythema infectiosum Slapped face disease Aust Fam Physician, 1988; 17: 737–8 Wilson JD et al Harrison’s Principles of Internal Medicine (12th edn) New York: McGraw-Hill, 1991: 1462–3 Golledge C A case of persistent cough Aust Fam Physician, 1997; 26: 1219 Spicer WJ (Chair) Antibiotic Guidelines (Version 13) Melbourne: Therapeutic Guidelines, 2006: 249–51 Hogan P Impetigo Aust Fam Physician, 1998; 27(8): 735–6 Marley J (Chair) Dermatology Guidelines (Version 3) Melbourne: Therapeutic Guidelines, 2009: 163–4 10 Ibid.: 178–80 11 Hipolito RB, et al Head lice infestation: single drug versus combination therapy with one percent permethrin and trimethoprim/sulfamethoxazole Pediatrics, 2001; 107: e30 Murtagh - General Practice (5e) Part 4.indd 890 22/10/10 2:42:56 PM Behaviour disorders in children 85 The habit of constantly gratifying every wayward wish and temper under the plea of illness, and the constant indulgence which it meets with in this form from a mother’s overkindness, exert a most injurious influence on the child’s character, and it grows up a juvenile hypochondriac C H A R L E S W E S T ( 1816– 98 ) , FOUNDER OF THE G R E AT O R M O N D S T R E E T H O S P I TA L The prevalence of significant psychiatric disorders in children in Western society is at least 12% in the age range 1–14 years, with an increase of 3–4% after puberty.1 Most of these disorders are externalised as behavioural (mainly aggression, opposition and hyperactivity) but there is a significant incidence of internalisation with emotional disorders, such as anxiety and depression, which tend to be misdiagnosed, as there is a perception that children not suffer from these psychiatric disorders in the same way as adults The authors have observed that most of the personality characteristics and behavioural problems of infancy tend to remain throughout childhood and adolescence and form the personality and behavioural disposition of the adult, although many associated problems not tend to persist into adult life Parry,2 who describes the five phases of childhood development (see Table 85.1), emphasises the importance of the first phase of infancy (where the infant is learning to trust the environment) as crucial to overall normal development Table 85.1 The five phases of childhood development Infancy Sense of trust Early childhood Sense of autonomy (independence) Preschool Sense of initiative School age Sense of industry Adolescence Sense of identity The second phase, in which the child is developing independent skills in the second and third years of life, is also an important phase and needs to be based on a secure and smooth first phase It is in this toddler stage that many of the behavioural disorders will be discussed FOR SICK CHILDREN Origins of behavioural problems3 Some of the causes proposed include: • accidental rewards for misbehaviour such as attention, material rewards and food • escalation traps, that is, giving in to the ‘dripping tap’ child • ignoring good behaviour • learning through watching, that is, acting like mum and dad • inappropriate instructions: too many, too few, too hard, poorly timed, too vague, ‘rapid fire’, body language • inappropriate emotional messages: angry, guilt inducing, character assassinations • ineffective use of punishments: threats not carried out, punishment in anger or in response to crisis, inconsistency • absenteeism: unavailability, lack of interest, lack of praise for good behaviour Oppositional behaviour Resistant and oppositional behaviour is common and perhaps normal from time to time provided it is not associated with antisocial behaviour It is a feature of 2–4 year olds as well as school-age children and adolescents It includes the common ‘won’ts’ (won’t eat, sleep, go to bed, obey) and temper tantrums, head banging, breath holding and biting It is important to interview the child and family to determine whether it is normal or abnormal Generally, supportive counselling and behaviour modification works effectively This includes looking for and praising or rewarding good behaviour It is important to praise (or chastise) behaviour rather than the child ‘Time out’ is the preferred disciplinary measure for children over 18 months (maximum minute per year of age) while withdrawing privileges is appropriate for children over years 891 Murtagh - General Practice (5e) Part 4.indd 891 22/10/10 2:42:57 PM 892 Part Four Child and adolescent health Temper tantrums The tantrum is a feature of the ‘terrible twos’ toddler whose protestation to frustration is a dramatic reaction of kicking, shouting, screaming, breath-holding, throwing, or banging of the head They usually start at 15–18 months and often persist until 3–4 years.4 Tantrums are more likely to occur if the child is tired or bored This behaviour may be perpetuated if the tantrums are inadvertently rewarded by the parents to seek peace and avoid conflict A careful history is required to gain insight into the family stresses; it also allows parents to ventilate their feelings Ask the parents exactly what the child does during a tantrum—what they during and after and what causes the tantrums Tantrums may be a pointer to an autism spectrum disorder Management Reassure parents that the tantrums are relatively commonplace and not harmful They are a common developmental issue and related to oppositional behaviour Explain the reasons for the tantrums and include the concept that ‘temper tantrums need an audience’ Advice2 • Ignore what is ignorable: parents should pretend to ignore the behaviour and leave the child alone without comment, including moving to a different area (but not locking the child in its room) • Stay calm, move away and say nothing • Don’t give in • Avoid what is avoidable: try to avoid the cause or causes of the tantrums (e.g visiting the supermarket) • Distract what is distractible: redirect the child’s interest to some other object or activity • Praise appropriate behaviour • Make sure that the child is safe When ignored, the problem will probably get worse for a few days before it starts to improve Medication has no place in the management of temper tantrums Breath-holding attacks The age group for the attack is months to years (peak 2–3 years) There are two distinct types—one occurring with a tantrum and the other a simple faint in response to pain or fright They can also manifest as ‘blue attacks’ due to breath-holding with a closed glottis or ‘white attacks’ known as reflex anoxic seizures, often in response to pain The precipitating event can be of a minor emotional or physical nature but usually frustration In the tantrum situation children will emit a loud cry, then hold their breath at the end of expiration Murtagh - General Practice (5e) Part 4.indd 892 They become pale, then cyanosed (this distinguishes it from a seizure disorder) If prolonged it may result in jerky movements, unconsciousness or a fit The episode lasts 10–60 seconds (see pages 915–16) Management Place the child in the coma position Reassure parents that the attacks are self-limiting and are not associated with epilepsy or intellectual disability Advise parents to maintain discipline and to resist spoiling the child Try to avoid incidents known to frustrate the child or to precipitate a tantrum by distraction methods Explain to parents that gently flicking cold water in the child’s face may abort the attack Head banging This behaviour is common, occurring in 5–15% of normal infants and toddlers.4 It also occurs in developmental disability and severe emotional deprivation It is quite different from a child hitting the head with the hands Features Occurs in children under 4, especially years old Usually prior to going to sleep Head banging occurs 60–80 times/minute Lasts several minutes to 60 minutes or more per episode Associated repetitive movements (e.g body rocking, thumb sucking) • Child usually not distressed and rarely self-injurious • Consider an autism spectrum disorder • • • • • Management • Reassure parents that it’s a self-limiting behaviour and usually settles by 3–5 years • Avoid reinforcing behaviour by excessive attention or punishment • Advise distraction or actively ignoring the behaviour • Place the bed or cot in the middle of the room away from a wall (reduces disruption from noise) • Restrict bed time (if appropriate) Conduct disorders Conduct disorders affect 3–5% of children and represent the largest group of childhood psychiatric disorders Clinical features4 Antisocial behaviour that is repetitive and persistent Lack of guilt or remorse for offensive behaviour Generally poor interpersonal relationships Manipulative Tendency to aggressive, destructive, ‘criminal’ behaviour • Learning problems (about 50%) • Hyperactivity (one-third) • • • • • 22/10/10 2:42:57 PM Behaviour disorders in children Family and environmental factors4 • • • • • Disrupted childhood care Socially disadvantaged Lack of a warm, caring family Family violence: emotional, physical or sexual abuse Antisocial peer group exposure Management • Early intervention and family assistance to help provide a warm, caring family environment • Family therapy to reduce interfamily conflict • Appropriate educational programs to facilitate self-esteem and achievement • Provision of opportunities for interesting, socially positive activities (e.g sports, recreation, jobs, other skills) • Behaviour modification programs • With physically aggressive behaviour, refer for psychotherapy if repeated, severe, causes injury or is associated with other antisocial behaviour Stealing Isolated theft, which is common, is not necessarily an indication of serious psychopathology but may reflect normal risk-taking behaviour, a reaction to stress, low self-esteem, searching for peer group acceptance or a ‘cry for help and attention’.4 Management • Insist on retribution—return of goods or payment and personal apologies to the ‘victim’ • ‘Punish’ with withdrawal of appropriate privileges • Refer for psychotherapy if persistent Sleep disorders/parainsomnias Refer to Chapter 72 Poor eating Some parents may complain that their toddler ‘eats nothing’ Apart from taking a careful history about what constitutes ‘nothing’, it is useful to describe the typical diet for the age group and then match the child’s weight on the normal growth chart The important aspect of management is to point out what is necessary from a nutritional viewpoint as opposed to what is considered normal for the particular culture Attention deficit hyperactivity disorder ADHD, which is characterised by developmentally inappropriate degrees of inattentiveness, overactivity and impulsiveness, has an estimated prevalence of Murtagh - General Practice (5e) Part 4.indd 893 893 about 2–5% It is far more common in boys than girls (6:1) and is usually present from infancy.1 About 60% will carry some degree of the disorder into adulthood A neurological basis for ADHD has been demonstrated Accurate diagnosis of ADHD is very important but can be problematic It is usually inappropriate to make a diagnosis under the age of years Diagnostic criteria A Either or (refer to diagnostic criteria for ADHD in DSM IV): inattention hyperactivity and impulsiveness B Onset no later than years of age C Symptoms must be present in two or more situations (e.g at school and at home) D Disturbance causes clinically significant distress or impairment in social, academic or occupational functioning E Not part of a pervasive developmental disability, psychotic disorder, mood disorder, anxiety disorder, associative disorder or a personality disorder 85 Other clinical features (may be present) • • • • • • Irritability and moodiness Poor coordination (clumsiness) Disorganisation Social clumsiness Learning difficulties Low self-esteem Differential diagnoses • • • • Auditory processing disorder Mild intellectual disability Learning difficulty Family psychosocial stresses Diagnosis • No foolproof diagnostic tests available • Psychometric tests available • Questionnaires (such as Conners Rating Scale) for parents and teachers Assessment should include child and family interviews, neurological examination, assessment of vision and hearing levels, serum lead levels (in high-risk groups) and the testing of formal cognitive achievement Twenty-five per cent of children with ADHD have coexistent learning disabilities.4 It is essential that an accurate diagnosis be made before treatment is commenced Shared care is an important principle and referral to a consultant is recommended.5 Management • Protect child’s self-esteem • Counsel and support family • Involve teachers 22/10/10 2:42:57 PM 894 Part Four Child and adolescent health • Refer to appropriate consultant (e.g child psychiatrist) • Refer to parent support group Diet Exclusion diet probably ineffective but encourage good diet (consider dietitian’s help) Pharmacological Based on psychostimulants for >4 years (2 doses: after breakfast and lunch):4,5 methylphenidate (Ritalin) 0.3–1 mg/kg (o) daily in divided doses (usually mg once or twice daily at first) or dexamphetamine 0.15–0.5 mg/kg (o) daily (usually 2.5 mg once or twice daily at first) Other available agents: • methylphenidate extended release tabs • atomoxetine Medication should be commenced at the low end of the dose range and gradually increased until satisfactory response or adverse effects (e.g movement disorders, nervousness, psychosis): • antidepressants, second line • clonidine, especially for sleep disturbance and aggression 12 months or so It is recommended before years of age and preferably from 2½ years Excellent results are obtained in over 90% of cases Habit cough This is a common problem usually affecting school-age children and occurs in the absence of underlying disease It only occurs when the child is awake—not during sleep Habit cough is usually loud, harsh, honking or barking It may follow an URTI and last for months It is a diagnosis by exclusion including PFTs and CXR Underlying triggers include inter-family problems and bullying or other perceived stress or anxiety Management includes explanation, reassurance and CBT Referral for resistant cases is appropriate Other functional respiratory problems • Hyperventilation • Sighing dyspnoea • Vocal cord dysfunction (see Chapter 58, page 602) Sibling rivalry Sibling rivalry is a real concern as a toddler acts out apparent jealousy towards a new baby The baby needs help from the inappropriate prodding, pinching and smothering attempts The jealous toddler needs attention from the mother and a fair share of the comforts, cuddling and love that the toddler has been used to having It is important that the toddler is encouraged to feel that it is his or her baby too and to have opportunities to experience warmth and smiles from the baby, so that a sense of belonging is engendered Stuttering and stammering This interruption of the orderly flow of speech may be accompanied by blinking and various other tics It tends to be common in the school years but at least 80% of sufferers become fluent by adulthood.6 Some children who stutter may avoid speaking Features (stuttering) Tics (habit spasm) Tics are ‘sudden, rapid and involuntary movements of circumscribed muscle groups which serve no apparent purpose’.6 Most are minor, transient facial tics, nose twitching, or vocal tics such as grunts, throat clearing and staccato semi-coughs Most of these tics resolve spontaneously (usually in less than a year) and reassurance can be given Tourette disorder Also known as Gilles de la Tourette syndrome or multiple tic disorder, Tourette disorder usually first appears in children between the ages of and 15 years (before 18 years) and has a prevalence of in 10 000 Diagnosis is based on recurrent tics over a period >1 year in which there is never a tic-free period for more than months Clinical features More common in boys Bizarre multiple motor tics One or more vocal tics Echolalia (repetition of others’ words) Coprolalia (compulsive utterances of obscene words) Palilalia (repeating one’s own words) Familial: dominant gene with variable expression • More common in boys • Has a familial pattern • Usually begins under years of age (starts between and years) • No evidence of neurotic or neurological disorder • Causes anxiety and social withdrawal • • • • • • • Management Treatment Although most stutterers improve spontaneously, speech therapy from a caring empathic speech pathologist is very helpful in those with stuttering persisting beyond The basis of treatment is psychoeducation, including reassurance that the person is not responsible for their tics Murtagh - General Practice (5e) Part 4.indd 894 22/10/10 2:42:57 PM Behaviour disorders in children • Promote their self-esteem • Consider TD support groups Table 85.2 A guide to the diagnosis of autistic disorder10 Medical treatment (if necessary) is haloperidol, clonidine or pimozide.5 Onset during infancy and early childhood An impairment of social interactions shown by at least two of the following: • lack of awareness of the feelings of others • absent or abnormal comfort seeking in response to distress • lack of imitation • absent or abnormal social play • impaired ability to socialise, which may include gaze avoidance Impairment in communication as shown by at least one of the following: • lack of babbling, gesture, mime or spoken language • absent or abnormal non-verbal communication • abnormalities in the form or content of speech • poor ability to initiate or sustain conversation • abnormal speech production Autism spectrum disorders Autism spectrum disorders (pervasive development disorders, PDD) are lifelong neurodevelopmental disorders with onset before 36 months of age A characteristic feature is impairment of social interaction, verbal and non-verbal communication skills and stereotyped behaviour and activities.8 Diagnosis requires the presence of three core features by years of age: • qualitative impairment of social interaction • qualitative impairment of communication • restricted, repetitive and stereotyped patterns of activities, behaviour and interest The spectrum can be grouped (after DSM IV) as: Restricted or repetitive range of activities, interests and imaginative development, shown in at least one of the following: • stereotyped body movements • persistent and unusual preoccupations and rituals with objects or activities • severe distress over changes in routine or environment • an absence of imaginative and symbolic play Behavioural problems: • tantrums • hyperactivity • destructiveness • risk-taking activity • autistic disorder • Asperger disorder • atypical autism or PDD not otherwise specified (PDDNOS) • Rett syndrome • childhood disintegrative disorder However, there is a wide range of presentations within the spectrum, with overlapping between the first three mentioned Autistic disorder Described first by Kanner in 1943, it is a PDD commencing early in childhood; it affects at least four children in 10 000, boys three to four times as commonly as girls It is not due to faulty parenting or birth trauma, but is a biological disorder of the CNS which may have multiple organic aetiologies There is a genetic link with a recurrence rate in families of up to 6%.9 Many autistic children appear physically healthy and well developed although there is an association with a range of other disorders, such as Tourette disorder, tuberous sclerosis, epilepsy (up to 30% onset, usually in adolescence) and rubella encephalopathy Most have intellectual disability but about 30% function in the normal range The children show many disturbed behaviours The main features are presented in Table 85.2 The earliest signs of autistic spectrum disorder in infancy include:8 • excessive crying • no response to cuddling if crying • failure to mould the body in anticipation of being picked up Murtagh - General Practice (5e) Part 4.indd 895 895 85 Source: After Tongue 10 stiffening the body or resisting when being held no babbling by year resistance to a change in routine appearing to be deaf failing to respond or overacting to sensory stimuli persistent failure to imitate, such as waving goodbye • a need for minimal sleep • no single words by 16 months • • • • • • The diagnosis remains difficult before the age of years (see red flag pointers for autistic spectrum disorders).11 Latter features: • fascination with certain toys/objects • poor interaction with other children (e.g play) • not pointing to objects (e.g grabs parent’s hands to show things) 22/10/10 2:42:57 PM 896 Part Four Child and adolescent health Asperger disorder 5, Also known as high-functioning autism, Asperger disorder or syndrome is a developmental disability As in autistic disorder, features include impairment in social interaction and in communication skills, with repetitive and restricted interests but (usually) no significant language delay It is usually diagnosed at age or older but can be readily diagnosed from years onwards (see red flag pointers).11 ‘Red flag’ pointers for Autistic spectrum disorders in babies11 Parents and doctors should consider evaluating a baby with two or more signs of the following: Impairment in social interaction • Lack of appropriate eye contact • Lack of warm, joyful expressions • Lack of sharing interest or enjoyment • Lack of response to name Impairment in communication • Lack of showing gestures • Lack of coordination of non-verbal communication • Unusual prosody (little variation in pitch, odd intonation, irregular rhythm, unusual voice quality) Repetitive behaviours and restricted interests • Repetitive movements with objects • Repetitive movements or posturing of body, arms, hands or fingers Typical characteristics are: • • • • • • • • • • • • marked male preponderance normal or borderline intellectual ability normal (may be precocious) speech development emotional blunting fixed and rigid routines (e.g bed time routine, coffee time and place in morning); the child can become very distressed if not met rigid/intolerant of change anxiety awkward motor skills/clumsiness mechanical, almost robotic patterns of speech lack of empathy or feeling lack of common sense obsessive focus on narrow interest (e.g reciting train schedules, weather patterns, dinosaurs) People with Asperger disorder usually seek friendships but lack the skills to make and maintain them Murtagh - General Practice (5e) Part 4.indd 896 Examples of behaviour They have difficulty: • in greeting someone appropriately and taking turns in conversation • reading body language, such as noticing the signs that someone is bored, happy or sad • understanding metaphor and common expressions (e.g they look bemused to their feet when told ‘pull up your socks’) As a rule they can learn social rules and behaviour and so minimise or reduce their disability, but their fundamental difficulties tend to persist throughout life Rett syndrome This is a severe neurodevelopmental disorder that affects only females After an apparent normal development for months, regression occurs with deceleration of head growth between and 48 months There is loss of acquired hand skills and social engagement Gait apraxia and ataxia manifest and eventually immobility and weakness Other features include autism, loss of speech, stereotyped hand wringing and seizures Atypical autism (PDDNOS) This diagnosis applies to the presence of core autistic behaviours but the criteria for autistic disorders are not fully met However, management follows the same principles Assessment If a child has delayed and deviant development and autistic spectrum disorder is suspected, a comprehensive multidisciplinary assessment is necessary Referral to professionals (e.g Child Development Unit) is essential as accurate diagnosis is important Treatment 8,12 Many treatments have been tried and behavioural treatment methods have proved to be the most helpful Medications are unhelpful for autism per se although medications such as tranquillisers, antidepressants and anticonvulsants are helpful for associated disorders The best results are achieved by early diagnosis, followed by a firm and consistent home management and early intervention program Remedial education and speech therapy have an important place in management Case histories and ‘draw a dream’ A useful strategy for communicating with disturbed children and getting to the source of a behaviour problem is to ask them to ‘draw a dream’.13 Professor 22/10/10 2:42:58 PM Behaviour disorders in children Tonge believes that the dream is the royal road to the child’s mental processes and the family doctor is ideally placed to use this technique The following case studies concerning insomnia and nightmares illustrate the importance of these symptoms as reflecting a deep emotional problem in the child Case study 114 Steven, aged 6, was a bright, happy little boy until he developed an extraordinary and puzzling episode of insomnia, which was solved eventually by his teacher He presented to our group practice with his bemused mother who claimed that, suddenly, he would not and could not sleep His parents would be startled at night by the eerie vision of Steven standing silent and motionless beside their bed When not in his bed at night he would be found hiding under it or in his wardrobe His behaviour was normal otherwise, but his teacher reported that his schoolwork had deteriorated and that he was constantly falling asleep at his desk On direct questioning Steven was shy and evasive, claiming nothing was worrying him We considered it was a temporary phase of abnormal behaviour and advised conservative measures such as hot beverages, baths and exercises before retiring, but this strategy failed He was referred to a consultant who also failed to find the cause of the insomnia and advised long midnight jogs Eventually Steven’s teacher had the bright idea of asking all the children to draw the thing that scared or worried them the most, stipulating that it would be a ‘make believe’ picture Looking at the drawing depicting two robbers stealing his moneybox as he slept (see Fig 85.1), she tactfully confronted Steven, who admitted that his playmate had told him robbers would come one night, steal his moneybox and ‘bash’ him The final chapter of this story saw a happy Steven perched on a bank counter watching his money being counted, deposited in a huge safe and exchanged for a bank book Steven has slept normally ever since Figure 85.1 Steven’s drawing Murtagh - General Practice (5e) Part 4.indd 897 897 Case study 214 George, the second child of four children, seemed a normal healthy 3-year-old when his mother presented him for assessment For about months George had been having nightmares, episodes that fractured the entire household His mother, Mary, was absolutely frustrated by his nocturnal behaviour and said she was ‘at her wit’s end’ As she excitedly rattled off details of the family dilemma, I noted that she was intense and rather domineering but obviously a very conscientious and dutiful wife and mother She explained that George would wake her at night calling out to her because of a monster in his room or outside his window She had no idea about any causes for this problem and explained that ‘our household is very normal—no problems really’ She said George’s behaviour was otherwise normal and he was a healthy boy 85 Identifying the monster I then asked George about his problem but could elicit only very scant information Recalling the immense value of the ‘draw a dream’ strategy I asked him to draw the monster George quickly drew the monster as shown in Figure 85.2 I asked him about the monster and finally confronted him with the question: ‘Do you know who or what the monster is?’ ‘Mum,’ replied George, very matter-of-factly A shocked Mary looked unbelievingly at George and, for once, seemed stuck for words Realising the delicacy of the situation, I asked George to tell me what it was about his mother that worried him He offered the very revealing information: ‘I don’t think that she loves me She’s always yelling at me.’ Obviously the monster was George’s insecurity because George declared how much he did love his mother and was ‘scared’ of losing her love With appropriate counselling the outcome was good Figure 85.2 George’s drawing 22/10/10 2:42:58 PM 898 Part Four Child and adolescent health A lesson learned often is that it is important to ‘look close to home’ for any significant behaviour disorder or other psychological problem It is important to explore the relationship that is most meaningful to the affected person (e.g mother–daughter, father–son, student–teacher) The ‘draw a dream’ strategy revealed vital information in this case Childhood bullying Research indicates that childhood bullying is common and up to 50% tell no one about it It was associated with school truancy and depression Indicative signs • • • • • • • • • • • • School phobia: sham sickness and other excuses Being tense, tearful and miserable after school Reluctance to talk about happenings at school Poor appetite Functional symptoms (e.g habit cough) Repeated abdominal pains/headache Unexplained bruises, injuries, torn clothing, damaged books Lack of a close friend; not bringing peers home Crying during sleep Restless sleep with bad dreams Appearing unhappy or depressed Unexpected irritability and moods; temper outbursts It is important to encourage them to talk to their parents and/or family doctor and receive support Cognitive behaviour therapy works well When to refer1 • When child abuse is known or suspected • When an underlying medical problem is present • For assessment of associated psychological, family and related factors • For failed management, including simple behavioural and family support interventions Murtagh - General Practice (5e) Part 4.indd 898 Patient education resources Hand-out sheets from Murtagh’s Patient Education 5th edition: • Attention Deficit Hyperactivity Disorder, page 14 • Autism, page 15 • Autism: Asperger’s Syndrome, page 16 • Bullying of Children, page 21 • Stuttering, page 57 • Tantrums, page 58 REFERENCES Tonge BJ Behavioural, emotional and psychosomatic disorders in children and adolescents In: MIMS Disease Index (2nd edn) Sydney: IMS Publishing, 1996: 52–5 Parry TS Behavioural problems in toddlers Aust Fam Physician, 1986; 15: 1038–40 Lynch C Common Behavioural Problems in Children Melbourne: Monash University Proceedings of 31st Annual Update Course for GPs, 2009: 103–12 Efron D, Davey M, Reilly S In: Paxton G, Munro J Paediatric Handbook (7th edn) Melbourne: Blackwell Science, 2008: 151–67 Dowden J (Chair) Therapeutic Guidelines: Psychotropic (Version 6) Melbourne: Therapeutic Guidelines Ltd, 2008: 226–34 Robinson MJ Practical Paediatrics (2nd edn) Melbourne: Churchill Livingstone, 1990: 543–9 Powell C, Brazier A Psychological approaches to the management of respiratory symptoms in children and adolescents Paediatric Respiratory Reviews, 2004; 5: 214–24 Curran J, Tonge B Autism spectrum disorders In: Lennox N, Diggens J Management Guidelines: People with Developmental and Intellectual Disabilities Melbourne: Therapeutic Guidelines Ltd, 1999: 197–204 Thomson K, Tey D, Marks M Paediatric Handbook (8th edn) Oxford: Wiley-Blackwell, 2009: 173 10 Tonge BJ Autism Aust Fam Physician, 1989; 18: 247–50 11 Wetherby A, et al Early indicators of autism spectrum disorders in the second year of life Journal of Autism and Developmental Disorders, 2004; 34: 473–93 12 Curtis J Autism Patient Education, 1993; 22: 1239 13 Tonge BJ ‘I’m upset, you’re upset and so are my Mum and Dad’ Aust Fam Physician, 1983; 12: 497–9 14 Murtagh J Cautionary Tales Sydney: McGraw-Hill, 1992: 165–74 22/10/10 2:42:58 PM 86 Child abuse It is customary, but I think it is a mistake, to speak of happy childhood Children, however, are often overanxious and acutely sensitive Man ought to be man and master of his fate; but children are at the mercy of those around them S I R J O H N L U B B O C K , B A R O N A V E B U R Y (183 4–19 13) • • • • • physical neglect emotional sexual potential Physical abuse occurs most often in the first years of life, neglect in the first years and sexual abuse from years of age1 (see Fig 86.1) In a Community Services of Victoria study2 the distribution of child abuse was physical 15%, emotional 48%, sexual 9% and neglect 28% In another study,2 the findings were as follows: • • • • • QIZTJDBMBCVTF TFYVBMBCVTF OFHMFDU *ODJEFODF The description of the ‘battered child syndrome’ in 1962 provoked an awareness of a problem facing children that continues to increase in prominence The possibility of both physical and sexual abuse has to be kept in mind by the family doctor It may surface in families known to us as respectable and where a good trustful relationship exists between parents and doctor Another aspect of child abuse is neglect The various types of abuse are classified as: Girls are more likely to be abused than boys Girls are more often assaulted by someone they know Most of the adults who sexually abuse are men (>90%) About 75% of offenders are known to the child Abuse is the misuse of a power situation (e.g a close relative, coupled with the child’s immaturity) Definitions Child abuse can be defined by the nature of the abusive act or by the result of the abuse A parent, guardian or other carer can harm a child by a deliberate act or by failure to provide adequate care Physical abuse (non-accidental injury) Physical abuse is defined as ‘a child with a characteristic pattern of injuries, the explanation of which is not consistent with the pattern, or where there is definite information through acknowledgment or reasonable "HF ZFBST Figure 86.1 Typical relative age patterns for child abuse Source: After Bentovin1 suspicion that the injury was inflicted or knowingly not prevented by any person having custody, charge or care of the child’.1 Neglect Neglect is defined as ‘the privation of food, drink, medical care, stimulation or affection’ Emotional abuse Emotional abuse is the ‘systematic destruction of the child’s sense of self-esteem and competence, where competence is defined as the ability to act in social contexts’ Sexual abuse Sexual abuse in children is defined3 as ‘the involvement of dependent, developmentally immature children and adolescents in sexual activities that they not fully comprehend, to which they are unable to give informed consent, and which violate the social taboos’ 899 Murtagh - General Practice (5e) Part 4.indd 899 22/10/10 2:42:58 PM 900 Part Four Child and adolescent health Munchausen syndrome by proxy This is the term used when a parent or guardian creates an illness in a child so that the perpetrator can develop or maintain a relationship with medical staff or transfer their responsibilities A ‘devoted parent’ may continually present a child for medical treatment yet deny the origin of the problem—namely, the parent One study showed that in over 90% of cases the mother is the abuser.4 The abuse may be of physical or medical neglect The masquerade may be simple or very sophisticated Children may be indirectly abused by the lengthy or invasive investigations Be cautious where there has been unexplained illness or death of a sibling percentage of the total reporting to central registries This could be because there is underdiagnosis of the problem but it could also be because of underreporting Reasons given as to why GPs don’t report more cases of child abuse include: • • • • • • Incest • • Incest is legally defined as ‘intercourse between biological family members’ • Female genital mutilation This comprises all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons (WHO definition) It is also referred to as female circumcision Abuse: who and why?2 The real cause seems to be a combination of several interrelated factors: personal, familial, social/cultural and societal stress Abused children exist at all levels of society, although the majority of abused children who come to the attention of authorities are from families where there is high mobility, lack of education, loneliness, poverty, unemployment, inadequate housing and social isolation Sexual abuse, occurring alone, does not follow these patterns and can occur under any socioeconomic circumstance Both men and women physically abuse their children While women are the parents most responsible in cases of neglect and emotional abuse (probably because of a dominant role in child care, social and economic disadvantage and being the only one responsible for the care of children in a single parent arrangement), men are more likely to abuse their children sexually The child can be abused at any age (even adolescents can be victims of abuse and neglect) It is important to keep this in mind—it does happen It will always be difficult to take the first step but it is important and it can help, no matter how small that first step is Interviewing parents or guardians A skilled, sensitive, diplomatic interview is fundamental to management Guidelines include: • • • • a relaxed, non-judgmental approach sensitivity to all people involved appropriate questions—open-ended, not leading use verbatim quotes from the child where possible and wait silently for a reaction Physical abuse Physical abuse should be suspected, especially in a child aged under years, if certain physical or behavioural indicators in either the child or the parents are present Bruising, especially fingertip bruising, is the most common sign of the physically abused child Physical indicators:2 • • • • • • • Underdiagnosing and under-reporting2 • • Although the medical profession remains the foremost focus of child abuse reporting (they are the most likely to encounter injured children and are the most qualified to diagnose abuse), they still contribute only a small • • • Murtagh - General Practice (5e) Part 4.indd 900 concern about drain on time and finances lack of positive feedback about other cases lack of undergraduate education on the topic risk of alienation and stigmatisation to the family the feeling by some GPs that they can work on the problem with the family without outside intervention lack of trust or confidence in local officials and agencies uncertainty about what to personal and legal risks (i.e fear of court, libel suits, irate parents) reluctance until absolutely certain of diagnosis unexplained injury different explanations offered injury unlikely to have occurred in manner stated unreasonable delays between injury and presentation finger-shaped bruises (e.g thumb grip marks) multiple bruises/welts of different ages, especially on face, buttocks (see Fig 86.2), genitalia, earlobes bruises in babies who are not yet pulling themselves up to walk fractures (especially if child