Child Abuse - Recognition

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.

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 Münchhausen's syndrome by proxy (factitious illness 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).
  • Also includes 'non-contact' activities, e.g. 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.

Concepts¹

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 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.

Risk factors

• 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.

General principles¹

If you encounter a feature which alerts you to possible child abuse, follow these steps:

1. Listen and observe:
   • Take into account the history, symptoms and signs, any other information or disclosure from third parties, child's appearance, behaviour and interaction of child and carers.
2. 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.
3. Record:
   • Record what is said and observed, by whom, and why you are concerned.
4. 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 Initial management section below.
   • If child abuse cannot be excluded, ensure the child is reviewed.

History

• 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 and ask yourself 'What is a day like in the life of this child?'⁷
• If using interpreters, you may need one from outside the family.
• A child may show no outward signs of abuse and hide what is happening.

Examination

• Document all findings. Record signs on a body map - examples are available.^8,9
• 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 nose or mouth after apparent life-threatening event, with no clear explanation.
• Ingestion of toxic substance or drug overdose - may be deliberate or may suggest inadequate supervision.
• Hypernatraemia without clear medical cause - may be salt poisoning.
• Near-drowning, unexplained or suggesting 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.

Behaviour

Carers' behaviour

• Delayed presentation, reluctance to seek help, fear of medical examination.
• Bring child to different surgeries/departments (to avoid detection of repeated injuries).
• Unexplained denial or aggression.
• No explanation for the injuries, a story that changes on repetition, or child's story differs from carer's.
• Carers prevent health professional speaking to the child alone.
• Carers show hostility or excess punishment to the child, have unrealistic expectations, or are unresponsive to the child ('emotionally unavailable').
• Child is excessively meeting carer's needs (emotional or practical).

Child's behaviour

• Unexplained depression, anxiety, fearfulness, aggression or withdrawal, self-harm behaviours, running away from home.
• Marked change in behaviour or emotional state, not explained by known stressful event. Includes dissociation (episodes of 'detachment' outside the child's control).
• Emotional problems not consistent with age or known disorder, e.g. excessive tantrums, recurrent nightmares.
• Seems afraid of particular adults, or reluctant to be alone with them.
• 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 eyes (as if awaiting the next blow). This sign indicates a severe level of abuse.
• Abnormal interaction with carers, e.g. over-obedient, too eager to please.
• Low self-esteem, excessive clinginess, indiscriminately affection-seeking towards strangers.
• Does not seek comfort from carers when distressed.
• Role reversal - child controlling carers, very young children excessively comforting distressed carer.
• Secondary enuresis, encopresis (defaecation in inappropriate place), deliberate wetting.
• Habitual body-rocking.
• Unexplained absences from school.

Physical abuse - symptoms and signs^3,6

Bruising

• Bruising in the shape of a hand, ligature, stick, teeth mark, grip, fingertips or an implement.
• 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), neck and top of shoulder, anterior chest, abdomen.
• Multiple or symmetrical bruises; bruises similar in shape and size.

Thermal injuries (burns and cold injury)

• Burns:
  • Showing the shape of an implement, e.g. cigarette, iron.
  • On areas unlikely to be accidentally burned, e.g. backs of hands, soles of feet, buttocks, back[/i].
• Scalds:
  • 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 child's buttocks are pressed against the hot water container, so the central area is spared).
• Unexplained cold injury:
  • Hypothermia
  • 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 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

• Any fracture in a baby too young to walk or crawl.
• Multiple fractures in different stages of healing.
• Rib fractures, especially if in a young child or posterior fractures. There may be subdural haemorrhage due to the infant being squeezed and shaken.
• 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 below under Head and eye injuries.

Head and eye injuries

May occur from a blow to the head or from shaking.

• Intracranial injury with no major confirmed accidental trauma or medical cause, especially if child aged <3 years, there are other injuries, retinal haemorrhages, rib or long bone fractures, or with multiple subdural haemorrhages.
• Retinal haemorrhages or eye injury without major confirmed accidental trauma or medical explanation.
• Accidental skull fractures are 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.⁶

Internal injuries

• Intra-abdominal or intrathoracic injury without confirmed major accidental trauma.

Emotional abuse - symptoms and signs¹⁰

• 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 signs¹⁰

Note:

• Examination of the genitalia should only be performed by an expert (see Initial management section).
• 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 >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 known adult, e.g. relative or babysitter.
• Emotional or behavioural changes, e.g. depression, self-harm, low self-esteem, running away from home, eating disorders, insecurity, 'ultra-good' behaviour.
• Secondary enuresis, encopresis or faecal soiling.
• Pregnancy in girl <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 medical condition, e.g. UTI, worms, skin condition).
  • Unexplained genital or anal symptom that is associated with behavioural or emotional change.
  • Gaping anus observed during an examination (without a medical explanation, e.g. 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 suitable explanation.
  • Foreign body in the vagina or anus (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 >13.

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 e.g. scabies or headlice.
• Developmental delay - may be due to lack of stimulation, e.g. being kept in a cot or pram much of the time.
• 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 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.

• Medical causes of failure to thrive.
• Other causes of falls and accidental fractures, e.g. epilepsy.
• Conditions causing increased bruising, e.g. thrombocytopenia, leukaemia.
• Mongolian blue spot (a congenital mark) can resemble a bruise.
• Medical conditions predisposing to fractures, e.g. osteogenesis imperfecta, metabolic bone disease in neonates, rickets, osteoporosis, copper deficiency, osteomyelitis, leukaemia, and disseminated neuroblastoma.
• Glutaric aciduria may be a rare cause of subdural haematoma.

• Blood tests: full blood count, clotting screen.
• Skeletal survey. If abuse is strongly suspected, do a follow-up survey 2 weeks later - this may show the more subtle fractures.
• If suspected head injury: CT or MRI brain scan; may need ophthalmological assessment (for intra-ocular bleeding).
• Forensic dentists can interpret bite marks, differentiating animal from human ones, and sometimes identifying the abuser.
• If sexual abuse suspected, may need screening for sexually transmitted infections (carried out by an appropriately trained clinician, see below).
• Ultrasound may show soft tissue injury, e.g. muscle haematoma.
• Further investigations if required, to exclude differential diagnoses (above).

General principles

• The child's welfare is paramount. The child's best interests over-ride other considerations such as confidentiality, consent and the carer's interests.
• Where there is an immediate risk of serious harm to a child, act immediately (see below).
• Share information with other agencies on a 'need to know' basis.
• Where possible, and if compatible with the child's best interests:
  • Respect the child's views.
  • Obtain consent.
  • Involve the carers (if the child is competent, this must be with the child's agreement). Do not involve carers if this would compromise the child's safety or evidence.
• Keep full and contemporaneous records.
• Remember other children in the household - are they at risk?
• All doctors have a duty to safeguard children and to ensure follow-on care for the child:
  • The non-specialist's role is not to make a definite diagnosis of child abuse, but to recognise the possibility and enlist appropriate help.
  • The doctor concerned about a child must ensure follow-on care.

If a child discloses abuse to you¹⁰

• Stay calm; find a quiet place to talk.
• Believe in what you are being told. Listen, but do not press for information.
• Say that you are glad that the child told you.
• Explain that the abuse was not the child's fault. If it will help the child to cope, say that the abuser has a problem.
• Explain that you will do your best to help the child. Do not promise confidentiality.

Initial actions if you think a child may be at risk³

In primary care

1. Discuss your concerns with colleagues:
   • Within the team (e.g. another GP, health visitor, nurse, lead GP for child protection).
   • Outside the team:
     • With the designated child protection health professional for your practice.
     • If unavailable, with social services.
   • Document all your concerns, discussions and decisions.
2. After discussion, if you still have concerns that the child is at risk:
   • Refer the child and family to social services,
   • If you think it is an emergency (the child is at immediate risk of serious harm), then refer the child immediately to the police and social services for immediate action. The police can enter premises and remove a child to a place of safety for 72 hours. Examples of emergencies are:
     • Recent sexual assault (<72 hours ago) - see below.
     • The child is unprotected and at risk of serious harm.
     • Any baby with signs of non-accidental injury.
   • If possible (and if compatible with child's safety), agree the referral with the child and family.
3. Within 48 hours, confirm in writing any telephone referral you have made.
4. Social services should acknowledge your written referral within one working day of receipt. If not received within three working days, contact social services again.
5. If the child requires referral/admission to hospital, ensure the paediatrician is aware of your concerns. Check that the child has arrived and been seen. Consider faxing your referral letter directly to the hospital.

Hospital or accident and emergency

• When a child presents at hospital, enquire about previous admissions.
• If you suspect a child is at risk, consult with colleagues, e.g. a named professional for child protection or a consultant paediatrician.
• If there is a risk of immediate serious harm, refer to the police (as above), who can arrange emergency protection for the child.
• If the child is admitted:
  • A named consultant must be responsible for the child protection aspects of care.
  • The child must be thoroughly examined within 24 hours (unless too unwell).
• If there are concerns, do not discharge the child from A&E or a ward until there is:
  • An arranged plan for future care.
  • The child is registered with a GP. Notify the GP of hospital/A&E attendances.
• In a non-emergency situation, where it is thought best for the child to stay in hospital, but the parents (or a competent child) request discharge, get urgent legal advice. Explain to the family why clinical supervision is advised.
• A concern about suspected abuse must not be dismissed without proper consideration, including a second opinion if necessary.
• Roles: consultant paediatricians are central to the investigation and treatment of abused children, but have no legal authority to conduct a child protection inquiry. Therefore social services (and the police, in urgent cases) should be involved.

Suspected sexual abuse³

• Do not perform a forensic intimate examination unless you have the training and facilities to do so. (You may, if appropriate, perform a routine general examination to check general health or other injuries.)
• To obtain evidence of sexual abuse, a forensic examination should preferably be done within 24 hours of the event; up to 72 hours is acceptable. Therefore:
  • Where suspected sexual abuse has occurred <72 hours ago, there should be an immediate discussion between health professionals, social workers and the police regarding the need for a medical examination.
  • Where suspected sexual abuse occurred >72 hours ago, an examination should be done within 7-10 days.

Further action³

• Subsequent pathways for child protection are detailed elsewhere.¹¹
• Ensure that the child and family have follow-on care.⁵
• Medical records: ensure that child protection concerns are clearly identified (e.g. coded in computer records).
• The RCGP encourages GPs to take an active role in child protection, e.g. attending child protection case reviews.⁴
• Child abuse raises strong feelings; those dealing with it may need support.

• 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, e.g. 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.¹²