Child Abuse - Recognition of Injuries

Four categories of child abuse are generally recognised. It is possible that a child may suffer from more than one type of abuse at any one time.

• Physical abuse
• Emotional abuse
• Neglect
• Sexual abuse

Munchausen Syndrome by Proxy is also a form of child abuse.

• 7% of children suffer serious physical abuse as children at the hands of their parents or carers, including being deliberately hit with a fist or implement, burned or scalded.¹
• 6% of children are were neglected at home, including being left regularly without food as a young child, not having their medical needs attended to, or being left to fend for themselves, e.g. because parents were absent or had drug or alcohol problems.¹

Risk factors

• A history of previous injury to the child. Health visitors and social workers may have important knowledge of the family and social situation.
• Relationship problems, lack of family support and alcohol or drug problems may predispose to child abuse.
• A child with a disability may be at particular risk.
• Other risk factors to consider include:
  • Parents:
    • Social class IV & V
    • Poor, unemployed
    • Young/immature parents
    • Abused in childhood
    • Present co-habitee not the father
    • Domestic violence
    • Sporadic antenatal attender
    • Further pregnancies
    • Denies access to health visitor or social workers
    • Drugs/alcohol abuse
    • Illness
    • No social support
    • Denied request for termination
  • Child:
    • Premature - extra feeding, poor responder
    • 'Wrong' sex
    • Sick children
    • Under 2yrs old
    • Multiple births
    • First born
    • Any abnormality esp learning disabilities

• Although these symptoms and signs do not necessarily indicate that a child has been abused, they may help adults recognise that something is wrong.
• A child may be subjected to a combination of different kinds of abuse.
• It is also possible that a child may show no outward signs and hide what is happening from everyone.²

Symptoms

• Record the history word for word. Document everything that is seen and heard. Use open questions (e.g. what happened?) rather than leading questions (e.g. were you hit?)
• It is a common feature of non-accidental injury that the explanation of the injury by the carer is not consistent with the injury sustained or the developmental stage of the child
• There may be no explanation for the injuries or a story that changes on repetition. The child may offer an explanation at odds with that of the carer
• Physical abuse
  • There may be a delayed presentation of the injury
  • Unexplained recurrent injuries or burns
  • Improbable excuses or refusal to explain injuries
  • Wearing clothes to cover injuries, even in hot weather
  • Refusal to undress for gym
  • Chronic running away
  • Fear of medical help or examination
  • Self-destructive tendencies
  • Aggression towards others
  • Fear of physical contact, shrinking back if touched
  • Admitting that they are punished, but the punishment is excessive (such as a child being beaten every night to make him study)
  • Fear of suspected abuser being contacted
• Sexual Abuse
  • Being overly affectionate or knowledgeable in a sexual way inappropriate to the child's age
  • Medical problems such as chronic itching, pain in the genitals, venereal diseases
  • Other extreme reactions, such as depression, self-mutilation, suicide attempts, running away, overdoses, anorexia
  • Personality changes such as becoming insecure or clinging
  • Regressing to younger behaviour patterns such as thumb sucking or bringing out discarded cuddly toys
  • Sudden loss of appetite or compulsive eating
  • Being isolated or withdrawn
  • Inability to concentrate
  • Lack of trust or fear of someone they know well, such as not wanting to be alone with a babysitter or child minder
  • Starting to wet again, day or night/nightmares
  • Become worried about clothing being removed
  • Suddenly drawing sexually explicit pictures
  • Trying to be ultra-good or perfect; overreacting to criticism
• Emotional Abuse
  • Physical, mental and emotional development is delayed
  • Sudden speech disorders
  • Continual self-depreciation
  • Overreaction to mistakes
  • Extreme fear of any new situation
  • Neurotic behaviour (rocking, hair twisting, self-mutilation)
  • Extremes of passivity or aggression
• Neglect
  • Constant hunger
  • Poor personal hygiene
  • Constant tiredness
  • Poor state of clothing
  • Emaciation
  • Untreated medical problems
  • No social relationships
  • Compulsive scavenging
  • Destructive tendencies

Signs

A careful record of findings is essential for medico-legal reasons. Possible signs of non-accidental injury include:

• General appearance and behaviour of the child:
  • Concurrent failure to thrive: measure height, weight and, in the younger child, head circumference.
  • Frozen watchfulness: impassive facial appearance of the abused child who carefully tracks the examiner with his eyes.
• Parental behaviour:
  • Delay in seeking advice, minimisation or denial of symptoms, refusal to allow admission or proper treatment, aggression.
  • Interaction with his carers may provide important clues. Do the carers over-react to naughty behaviour and do they have unrealistic expectations of the child given his age?
• Age of child:
  • Any bruising to a young baby
  • It is unusual for a child under the age of 1 year to sustain a fracture accidentally.
• Multiple injuries: Multiple injuries of different ages are suspicious. The colour of bruises reflects their age.
• Repetitive pattern: recurrent visits, repeated injuries.
• Injuries that are not consistent with the story: too many, too severe, wrong place or pattern, child too young for the activity described
• Bruising:
  • Bruising patterns can suggest gripping (finger marks), slapping or beating with an object.
  • Bruising on the cheeks, head or around the pinna and black eyes can be the result of non-accidental injury.
  • Bruises on black children will be more difficult to identify.
  • Mongolian blue spots may be mistaken for bruises.
• Other injuries:
  • Bite marks may be evident from an impression of teeth.
  • Small circular burns on the skin suggest cigarette burns.
  • Scalding inflicted by immersion in hot water often affects buttocks or feet and legs symmetrically.
  • Red lines occur with ligature injuries.
  • Tearing of the frenulum of the upper lip occurs with force-feeding.
  • Fundal examination will identify retinal haemorrhages, which can occur with head injury and vigorous shaking of the baby.
• Head injury
  • Palpate the scalp to detect possible fracture sites.
  • Check fontanelle tension in infants for signs of raised intracranial pressure.
• Fractured ribs: rib fractures in a young child are suggestive of non-accidental injury.
• Other fractures: spiral fractures of the long bones are suggestive of non-accidental injury.

• Examination of the genitalia and anus should be performed by a paediatrician with experience in the area of sexual abuse; therefore, if the history points to this, refer urgently. It is important that the child is not subjected to multiple examinations.
• Any features that suggest interference with the genitalia.
• These may include bruising, swelling, abrasions or tears.
• Soreness, itching or unexplained bleeding from penis, vagina or anus.
• Sexual abuse may lead to secondary enuresis or faecal soiling and retention.
• Symptoms of a sexually transmitted disease such as vaginal discharge or genital warts, or pregnancy in adolescent girls.
• Children who have been sexually abused may demonstrate inappropriate sexual knowledge and behaviour.
• Low self-esteem, depression and self-harm are all associated with sexual abuse.
• Children may disclose sexual abuse themselves.

• Neglect can lead to failure to thrive, manifest by a fall away from initial centile lines in weight, height and head circumference. Repeated growth measurements are crucially important.
• Signs of malnutrition include wasted muscles and poor condition of skin and hair. It is important not to miss an organic cause of failure to thrive; if this is suspected, further investigations will be required.
• Lack of stimulation can result in developmental delay, for example, speech delay, and this may be picked up opportunistically or at formal development checks. Infants and children with neglect often show rapid growth catch-up and improved emotional response in a hospital environment.
• Children suffering from emotional abuse may be withdrawn and emotionally flat. One reaction is for the child to seek attention constantly or to be over-familiar. Lack of self-esteem and developmental delay are again likely to be present.
• Knowledge of the family situation is important. The carers may have had a deprived childhood themselves and have poor parenting skills.

Other reasons for exaggerated and recurrent trauma include:

• Increased falls, e.g. epilepsy. Although accidental injury is more likely in the child prone to falls or fits, or needing physical support, the possibility of non-accidental injury should still be considered.
• Increased bruising, e.g. thrombocytopenia, leukaemia.
• Medical conditions that could predispose to fractures, e.g. osteogenesis imperfecta, metabolic bone disease in neonates, rickets, osteoporosis, copper deficiency, osteomyelitis, leukaemia, and disseminated neuroblastoma.³

Secondary care investigation of suspected non-accidental injury

• Full blood count, coagulation screen: to exclude thrombocytopenia or abnormal clotting profile.
• X-ray skeletal survey: for evidence of past and present fractures suggestive of non-accidental injury.

The department of health has produced full guidance on the management of suspected child abuse.⁴ The British Medical Association has also produced guidance for doctors on their responsibilities in child protection cases.⁵

• If a GP suspects that a child has suffered non-accidental injury or sexual abuse, he should refer the child immediately for paediatric assessment.
• It is then the responsibility of the paediatrician to decide if the injury is accidental or not, or if sexual abuse has occurred, and to inform social services.
• If the child is thought to be in immediate danger, he should be admitted to a place of safety, which, in the case of a GP assessment, will usually be a hospital ward.
• When hospital admission is not immediately necessary, refer suspected cases of child abuse to social services.
• Whatever action is taken, it is important to try and maintain a relationship with the family of the child, as it is very likely that health and social services will have to work with them subsequently.

• Long-term physical and psychological problems for the child.

• Without appropriate intervention and parental education and support, child abuse is usually a recurrent and sometimes escalating problem.

• Early detection of at-risk families and appropriate intervention may prevent future abuse.
• Identification of children with less severe physical abuse may prevent more severe subsequent injuries or death.
• Educating parents in parenting skills and providing support for families.