- Why am I worried?
- What is the perceived level of risk?
- What are the implications of doing nothing or deferring action?
- What should I do right now?
Any doctor who suspects child abuse has the duty to act. Always try to gain consent and to share information and to involve a senior colleague. But if you believe that a child is in immediate danger, you can act in the child's best interests.
Recent General Medical Council (GMC) guidance says that all doctors have a duty to report concerns that a child may be at risk (this includes doctors working with adult patients where they suspect that their patient's child may be at risk).
Note: in this article, 'carers' refer to parents and/or others caring for a child. A 'child' refers to someone who has not reached their 18th birthday.
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Categories of abuse
Four categories of child abuse are generally recognised - a child may suffer more than one type at a time:
- Physical abuse: involves physical harm such as hitting, shaking, burning, poisoning or causing suffocation. Includes fabricated or induced illness by carers (FII) (factitious illness by proxy - formerly referred to as Münchhausen's syndrome by proxy).
- Emotional abuse: persistent emotional ill-treatment or neglect causing adverse effects on the child's emotional development. For example: making the child feel worthless; unrealistic expectations; preventing normal social activity; serious bullying; seeing the ill-treatment of another person; making a child often frightened; exploitation or corruption. Some level of emotional abuse is involved in all types of child abuse.
- Sexual abuse: forcing or enticing a child into sexual activity (this includes both penetrative and non-penetrative acts). It also includes 'non-contact' activities - eg, involvement in pornography; the child looking at sexual activities or pornographic material; or encouraging inappropriate sexual behaviour in a child.
- Neglect: the persistent failure to meet a child's basic physical or psychological needs, in a way likely to impair the child's health or development seriously. For example: not providing food or shelter; inadequate protection from danger; not enabling adequate medical care; emotional neglect.
Emotional abuse and neglect may reflect the carer's own health or social needs.
National Institute for Health and Clinical Excellence (NICE) guidance suggests the concepts of 'alerting features', 'consider' or 'suspect':
- 'Alerting features' are symptoms, signs and patterns of injury or behaviour, which may indicate child abuse.
- 'Consider' means that abuse is one possible explanation for an alerting feature (but there are other differential diagnoses).
- 'Suspect' means there is a serious level of concern about abuse, but it is not proof. It may trigger a child protection investigation. This may lead to child protection procedures, to offering the family more support, or may lead to alternative explanations being found.
Exact figures of abuse are not known, but a National Society for the Prevention of Cruelty to Children (NSPCC) survey found that:
- 7% of children suffered serious physical abuse.
- 6% of children suffered serious neglect.
- 6% suffered emotional abuse.
- 11% suffered sexual abuse from an unrelated but known person; 4% suffered sexual abuse within the family.
Child abuse causes 1-2 deaths per week in England - possibly more.
- Previous history of child abuse in the family (health visitors and social workers may have useful information).
- Domestic violence.
- Mental illness, physical illness or disability in the carers.
- Drug or alcohol misuse in the carers - especially if unstable or chaotic drug misuse.
- Housing or financial problems.
- Disability in the child.
- Single parents, especially if immature or unsupported.
- Some children are vulnerable to being 'lost' by the system - for example, where the families are homeless, asylum seekers, or where children are carers or young offenders.
If you encounter a feature which alerts you to possible child abuse, follow these steps:
- Listen and observe: take into account the history, symptoms and signs, any other information or disclosure from third parties, the child's appearance, behaviour and interaction of the child and carers.
- Seek an explanation: enquire in an open and non-judgemental way, as to the explanation for injuries or other features. An unsuitable explanation is:
- Inconsistent with child's age, development, medical condition, history of the injury.
- Inconsistent between carers, differs from child's account or changes over time.
- Cultural practices are not an acceptable excuse for hurting a child.
- Record: what is said and observed, by whom, and why you are concerned.
- If at this point you are considering or suspecting child abuse: think about your level of concern and whether there is immediate danger to the child. Then discuss with colleagues, refer and/or seek more information (see separate article Safeguarding Children - Referral and Management of an Abused or At-risk Child). If child abuse cannot be excluded, ensure the child is reviewed.
- Listen; use open and non-judgemental questions ('What happened?') rather than leading questions ('Were you hit?').
- Where possible, have separate communication with the child, in a way which helps develop trust. Consider taking a history directly from the child, if it is in their best interests. If necessary, this may be done without the carer's consent - but document your reasons.
- Listen to the child. Ask yourself 'What is a day like in the life of this child?'
- If using interpreters, you may need one from outside the family.
- Note: the child may show no outward signs of abuse and hide what is happening.
- Document all findings. Record signs on a body map - examples are available. 
- Consent should be obtained for a physical examination which is specifically for the purpose of child protection. Consent may be given by the child if competent, by a person with parental responsibility, or by the court. However, in an emergency, it may be in the child's best interest to have this examination without explicit consent. If so, document the reasons.
- Assess the whole child and all the injuries present.
The following are possible symptoms and signs of child abuse. Usually, one single feature is not diagnostic of abuse - more important is the overall pattern or combination of features.
Patterns of injury or illness
- Injuries which are multiple, frequent, or of different ages.
- Injury is not consistent with history stated or the developmental age of child. For example, bruising in a baby, fractures in infants, injury too severe for the cause described.
- Repeated apparent life-threatening events, if witnessed by only one carer and no medical explanation.
- Infant with bleeding from the nose or mouth after an apparent life-threatening event, with no clear explanation.
- Ingestion of a toxic substance or a drug overdose - may be deliberate or may suggest inadequate supervision.
- Hypernatraemia without a clear medical cause - may be salt poisoning.
- Near-drowning (either if unexplained or from lack of supervision).
Consider fabricated illness where reported symptoms or response to treatment do not seem plausible, or where symptoms are only ever observed by the carer.
- Delayed presentation, reluctance to seek help, fear of medical examination, brings child to different surgeries/departments (to avoid detection of repeated injuries).
- No explanation for the injuries, a story that changes on repetition, or the child's story differs from the carer's.
- Unexplained denial or aggression, won't let health workers see the child alone.
- Carers show hostility or excess punishment to the child, have unrealistic expectations, or are unresponsive to the child ('emotionally unavailable').
- Carer not responding emotionally to the child or not interacting with the child (eg, not conversing, playing with, praising or comforting the child).
- The child is excessively meeting the carer's needs (emotional or practical).
- Unexplained depression, anxiety, fearfulness, aggression or withdrawal, self-harm behaviours, body rocking,
- Marked change in behaviour or emotional state, not explained by known stressful event, including secondary enuresis or encopresis.
- Emotional problems not consistent with age or known disorder - eg, excessive tantrums, recurrent nightmares.
- Lack of normal behaviour towards a carer or adult - seems afraid, over-obedient, role reversal (the child taking the adult role with the carer), not seeking comfort when distressed.
- Unusual reluctance to undress, fear of physical contact, or extreme passivity during medical assessment.
- Frozen watchfulness: the child looks watchful yet unresponsive, carefully tracking the adults with his or her eyes (as if awaiting the next blow). This sign indicates a severe level of abuse.
- Running away from home, unexplained absence from school.
Neglect - symptoms and signs
- Malnutrition or failure to thrive - measure height, weight and use growth charts.
- Excessive crying, tiredness, hunger or scavenging.
- Poor hygiene and clothing; severe and persistent infestations - eg, scabies or headlice.
- Developmental delay - may be due to lack of stimulation - eg, being kept in a cot or pram much of the time.
- The child often left alone or left in unsafe situations - accidental injuries may indicate lack of appropriate supervision.
- Frequent school absence.
- Untreated medical problems, including untreated dental decay (where NHS treatment is available).
- Persistent failure to attend important child health programmes or follow-up appointments.
- No social relationships.
- Emotional or behavioural symptoms (see under 'Behaviour', above).
- Often show catch-up growth and improved emotional response in a new environment.
- Bruising in the shape of an object - fingertips, hand, ligature, stick, teeth mark or implement such as belt buckle. Note that beating from rod-shaped instruments such as a stick can leave 'tramline bruising' (parallel lines of bruising due to blood being pushed sideways, away from the impact of the rod).
- Petechiae (tiny red or purple spots) not caused by a medical condition - may be due to shaking or suffocation.
- Bruises at sites where accidental bruising is unusual: face, eyes, ears (bruising around the pinna may be subtle), the 'safe triangle' of the neck (the neck and top of the shoulder), inner arms, anterior chest, abdomen, groins.
- Multiple or symmetrical bruises.
NB: accidental bruises tend to be on bony prominences. Accidental bruises in children are most commonly found on knees, shins, elbows, palms, chin, nose, forehead, occiput or parietal bone.
The age of a bruise cannot be exactly determined from its colour, but bruises show a progression of colour change over time (red/purple/blue initially, followed by green/yellow/brown).
Thermal injuries (burns and cold injury):
- Burns and scalds:
- Deliberate contact burns tend to be: multiple; have a clearly demarcated edge and involve unusual areas of the body such as the back, shoulders or buttocks, backs of hands, soles of feet; may show the shape of an implement - eg, cigarette, iron.
- Accidental burns tend to be: on palm of the hand; often a single burn or at most two burn areas; not well demarcated (as the skin may have had only glancing contact with the hot object); hair straighteners may leave a burn on each side of the hand or ankle.If doing a home visit, look at the environment to see if the burn could have occurred in this environment.
- Deliberate scalds tend to have clear demarcation and a symmetrical pattern. (This contrasts with accidental scalds where the child will quickly try to withdraw and the burn pattern will probably be irregular.)
- Suspicious patterns are a glove or sock pattern, or a 'doughnut' pattern (where a child's buttocks are pressed against the hot water container, so the central area is spared).
- Unexplained cold injury:
- Cold injuries (for example, swollen, red hands or feet).
Other surface marks:
- Human bite marks (if unlikely to be from young child).
- Lash marks.
- Red lines around the neck, wrist or ankles, from tying up.
- Oral injury, including torn frenulum of the upper lip.
- Lacerations, abrasions or scars in sites where accidental injuries are unusual (as for 'Bruising', above).
- Fractures not in keeping with developmental age, including any fracture in a baby too young to walk or crawl, or femoral fracture in child not yet walking.
- Multiple fractures in different stages of healing.
- Rib fractures or spinal injury (unless the child was in a major accident).
- Sternal fracture.
- Long bones - metaphyseal or spiral fractures; subperiosteal haemorrhage (occurs with pulling/grabbing, may not be visible on X-ray until 14 days later).
- Spinal injuries without confirmed major accidental trauma.
- Skull fractures - see under 'Head and eye injuries', below.
Head and eye injuries:
These may occur from a blow to the head or from shaking. Brain injuries of all types can occur in child abuse - most commonly subdural haemorrhages (SDHs), with or without subarachnoid haemorrhages (SAHs).
Pointers towards abuse are:
- Multiple SAH or SDH.
- Combination of brain injury, retinal haemorrhage and rib fractures (due to the child being squeezed and shaken).
- Retinal haemorrhages or eye injury without any major accident.
- Accidental skull fractures being rare in children <5 years, even after a fall of 90 cm. A history of a fall from a bed or sofa should be questioned.
- Intra-abdominal or intrathoracic injury without confirmed major accidental trauma.
Two patterns of non-accidental injury are described: neck injuries and chest or lower back injuries.
- Neck injury: usually with co-existing inflicted brain injury and/or retinal haemorrhages; mainly in infants aged <4 months; may not be obvious, as the child is often unconscious and difficult to assess; if conscious,the baby may be reluctant or distressed when its neck is moved.
- Chest or lower back injuries: in toddlers, showing EITHER signs of spinal injury OR an obvious deformity, such as spinal curvature or swelling of the lower back. These injuries are often severe - fatal or causing permanent paralysis.
Emotional abuse - symptoms and signs
- Delayed development (physical, mental or emotional; speech disorders).
- Low self-esteem, self-blame, over-reaction to mistakes.
- Carers repeatedly humiliate the child.
- Behavioural symptoms (as above).
Sexual abuse - symptoms and signs
- Examination of the genitalia should only be performed by an expert (see separate article Safeguarding Children - Referral and Management of an Abused or At-risk Child).
- Sexual activity with a child aged <13 years, by law is sexual abuse; the child's 'consent' is irrelevant at this age.
- For a child aged >13 who has had sex, consider whether the relationship with their partner is consensual and equal. For example, is the partner of similar age and maturity to the child?
- Be concerned if the partner is not a peer, if there is an imbalance of power, imbalance of mental capacity, or the partner is in a position of trust.
Possible symptoms and signs are:
- Sexual behaviour or knowledge inappropriate to age; sexually explicit play.
- Unexplained fear of a known adult - eg, a relative or babysitter.
- Emotional or behavioural changes - eg, depression, self harm, low self-esteem, running away from home, eating disorders, insecurity, 'ultra-good' behaviour.
- Secondary enuresis, encopresis or faecal soiling.
- Pregnancy in a girl aged <13; unexplained pregnancy; where the partner is not a peer.
- Genital symptoms and signs:
- Dysuria, soreness, itching, bleeding or discharge from genitals or anus, which is recurrent or persistent (and not explained by a medical condition - eg, urinary tract infection, worms, skin condition).
- An unexplained genital or anal symptom that is associated with behavioural or emotional change.
- Gaping anus observed during an examination (without a medical explanation - eg, a neurological disorder or severe constipation).
- Anal fissure - if constipation, Crohn's disease and passing hard stools have been excluded as the cause.
- Genital, anal or perianal injury without a suitable explanation.
- A foreign body in the vagina or anus (this may present as offensive vaginal discharge).
- Sexually transmitted infection (including genital warts, hepatitis B) without clear evidence of vertical transmission, or without a consensual sexual relationship in a child aged >13.
- Medical causes of failure to thrive.
- Other causes of falls and accidental fractures - eg, epilepsy.
- Conditions causing increased bruising - eg, thrombocytopenia, leukaemia.
- Mongolian blue spot (a congenital mark), which can resemble a bruise.
- Medical conditions predisposing to fractures - eg, osteogenesis imperfecta, metabolic bone disease in neonates, rickets, osteoporosis, copper deficiency, osteomyelitis, leukaemia, and disseminated neuroblastoma.
- Glutaric aciduria, which may be a rare cause of subdural haematoma.
- FBC, clotting screen.
Skeletal survey or bone scan:
- Where physical abuse is suspected in children aged <2 years, a skeletal survey or radionuclide bone scan is indicated. This may also be needed in some older children.
- This is needed if head injury is suspected clinically. Also, infants aged <1 year with any physical abuse injuries should have neuro-imaging for possible non-accidental brain injury.
- A child with abusive injuries and any signs or symptoms of brain injury should have neuro-imaging performed.
- If there is head injury, also arrange a retinal examination by an opthalmologist and a skeletal survey with oblique views of the ribs.
- A full skeletal survey (if indicated, as above) must include plain X-rays of the spine, including lateral views.
- If any fracture is seen or spinal cord injury is suspected, do an MRI of the spine.
- Consider the possibility of co-existing spinal injury in children with non-accidental brain injury - in such cases, arrange MRI of the spine if there are concerns about co-existing spinal injury.
- This can be used if there is suspected soft tissue injury - eg, muscle haematoma.
Sexual health tests:
- If sexual abuse is suspected, the child may need screening for sexually transmitted infections (carried out by an appropriately trained clinician; see separate article Safeguarding Children - Referral and Management of an Abused or At-risk Child).
- Forensic dentists can interpret bite marks, differentiating animal from human ones, and sometimes identifying the abuser.
- Specific investigations may be required to exclude the various differential diagnoses (above).
See separate article Safeguarding Children - Referral and Management of an Abused or At-risk Child. The child's welfare is paramount.
- These are doctors/nurses/midwives who provide advice and support in child protection to those working in a hospital, PCT or practice.
- There is also a 'designated professional' who has overall responsibility for child protection within a PCT.
- May enter premises and remove a child to a place of safety for 72 hours.
- Have child abuse investigation units, which normally take responsibility for investigating child abuse cases.
- All local authorities have a social services officer permanently on call (including out of hours) with access to the child protection register. This officer can take referrals if there are concerns about a child.
- The local authority has responsibility for the safety and welfare of children.
- Is a voluntary organisation authorised to initiate child protection proceedings.
- Has a national child protection helpline (freephone 0808 800 5000) and a children's helpline (Childline, freephone 0800 1111).
- The Local Safeguarding Children's Board (LSCB) has overall responsibility for deciding how the relevant organisations will work together to safeguard children in its area.
Prognosis and complications
- Without appropriate intervention, child abuse can be a recurrent or escalating problem. It may be fatal.
- The physical, emotional and social effects of abuse can be lifelong.
- Early identification and support of vulnerable children and families.
- Share information between agencies - eg, incidents of domestic violence can be notified to the GP and health visitor.
- When a parent or carer is ill, find out how the family and children are affected; enlist extra support if needed.
- For children with additional needs, the Common Assessment Framework is now used (in England) to assess the child's needs.
Further reading & references
- National Society for the Prevention of Cruelty to Children (NSPCC)
- Recognising child abuse - handbook 2009; Kent County Council. (Contains body map for recording injuries)
- Facial injury map - outline drawing of face and head for recording injuries
- When to suspect child maltreatment, NICE Clinical Guideline (July 2009)
- BMJ Learning; Modules on child protection: child protection - your responsibilities (parts 1 and 2) and child abuse - a guide to recognition and management; BMJ Publishing Group, 2009. (Requires registration - for doctors.)
- Protecting children and young people: The responsibilities of all doctors; General Medical Council, 2012
- Child protection - a tool kit for doctors; British Medical Association, May 2009
- Barber MA, Sibert JR; Diagnosing physical child abuse: the way forward. Postgrad Med J. 2000 Dec;76(902):743-9.
- The Victoria Climbie Memorial Lecture - Lord Laming, February 2007
- Recognising child abuse - handbook 2009; Kent County Council. (Contains body map for recording injuries)
- Facial injury map - outline drawing of face and head for recording injuries
- Leaflets for professionals, parents and children; National Society for Prevention of Cruelty to Children (NSPCC)
- Harris J et al; Child Protection and the Dental Team, Committee of Postgraduate Dental Deans, 2006
- Faller-Marquardt M, Pollak S, Schmidt U; Cigarette burns in forensic medicine. Forensic Sci Int. 2008 Apr 7;176(2-3):200-8. Epub 2007 Oct 31.
- Child Abuse - Signs and Symptoms; Kidscape
- Standards for radiological investigation of non-accidental injury, Royal College of Radiologists, 2008
|Original Author: Dr Colin Tidy||Current Version: Dr Colin Tidy||Peer Reviewer: Dr Tim Kenny|
|Last Checked: 20/11/2012||Document ID: 1936 Version: 23||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.