Injury variables in child abuse

Chid Rbuw & Ne&w. Vol. 9, pp. 207-215. Primed m the U.S.A. All iv&Is reserved.

1985 Cnpyngh:

014S-2134/85 f3.00 + .oO 9 1985 Pergamon Press Ltd.

INJURY VARIABJ_,ESIN CHILD ABUSE CHARLES FELZEN JOHNSON, M.D. Professor of Pediatrics, The Ohio State University, Director Child Abuse Program, Children’s Hospital, Columbus, Ohm 43205

JACY SHOWERS, ED.D., Educational Researcher-Consultant,

Child Abuse Program, Children’s Hospital, Cofumbus, Ohio 43205 f

Abstract-The child abuse reporting records of 616 children seen by the child abuse team in a metropolitan children’s hospital were analyzed. Boys were referred for abuse more often than girls, and black children were reported disproportionately more often than were white children. Mothers were the most freyJuent perpetrators of abuse, although males constituted more than half of the abusers. Bruises were the most frequent manifestation of abuse. The types of injury, injury site and types of instruments used varied with the age and race, but not the sex of the child. The wide variety of instruments used to perpetrate child abuse resulted in a broad spectrum of injury types. If prof~sion~s are to recognize common and early m~estations of child abuse, they must be aware of the in&tence of regional socioeconomic and cultural factors on the spectrum of child abuse. R&sum&-Les auteurs se sont penches sur les dossiers de 616 enfants amen&s dam un hopital municipal et vus par I’tquipe sptcialiste dans les s&ices a l’tgard d’enfants. I1 y avait plus de garc;ons que de filles et la proportion des enfants noirs etait disproportionnee par rapport a celle des enfants blancs. Le plus souvent, l’agresseur etait la mere quand les s&ices Ctaient causes par les parents, mais en fan, la agresseurs ttaient pour plus de la moitie des indi~dus du sexe masculin. On a trot& le plus souvent des hematomes. Le type de blessures, la locahsation de la blessure et Ie genre d’instrument utihst pour la causer a varie avec l’age et la race, mais pas selon le sexe de l’enfant, c’est-&-dire que les tilles ont subi Ie m&me genre de blessures que les gqns. Les s&ices ont tte it&g&s avec une t&s grande vat&C d’instruments, de sorte que le nombre de blessures difTerentes ttait trts grand. I1 est apparu aux auteurs que de vouloir interdire I’usage de la fessed ne pourrait que conduire a des manifestations de violence pires. De meme, I’interdiction des armes ne servirait pas a grand chose dans cette problematique puisque les lesions etaient souvent causees par des instruments domestiques t&s varies. Les facteurs socio&onomiques et culturels jouent certainement un role dam le type de lesion que l’on rencontre. Le diagnostic correct et pr&oce de ces l&ions est evidemment utile puisque l’on peut de cette fagon proteger l’enfant contre les r&dives. Key W’ordr-Child abuse identification, Non-accidental injury, Trauma, Socioeconomic and cultural variables.

WHAT WE KNOW ABOUT INJURIES AND PATTERNS OF INJURY IN CHILD ABUSE DESPITE INCREASED AWARENESS of the existence of child abuse and legislation which requires reporting suspected child abuse, there has not been complete “moral and legal compliance” among physicians [ 11.The reasons physicians find it difficult to establish or rule out the diagnosis of suspected child abuse have been studied retrospectively. Subjective factors were found to influence failure to report child abuse when symptoms, history, physical examiThis research was partially supported by a grant from the National Institute of Health to the Ohio State University Research Apprentice Program which provided the services of a research assistant, Darlynn Bell, to whom we wish to give acknowledgement. 207

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Charles Felzen Johnson and Jacy Showers

nation and laboratory evaluations did not confirm the suspicion [2]. Physicians are not alone in their failure to recognize or repor? child abuse; 41% of pedodontists, in one study. also

failed to report child abuse because of uncertainty about the diagnosis [3]. It is possible that health care providers who do not see a large number of children may fail to recognize injuries. patterns of injuries or items in the history which suggest non-accidental injury (NAIL The history given when a child is assessed for injury may suggest child abuse [4]: there are no pathognomonic injuries in child battering, although metaphyseal injury. spiral fractures. subdural hematoma and retinal hemorrhage (with or without a skull fracture), bruises or lacerations caused by looped cords or belts, human bites. bruises and fractures in various stages of healing, and immersion and cigarette burns are considered indicative of child abuse [5]. Bilateral injuries [6] and injuries to the genitalia [7] have been reported as alerting signs. The shape of a mark as well as its age may suggest NAI: circumferential injuries about the wrists or ankles may indicate that the child has been tied, and marks from choking are distinctive [8]. Until recently, penetrating injuries of the midsection of the body, possibly because of their rarity, have not lent themselves to suspicion for NAI [9]. These abdominal injuries have received more limited attention [lo-121 despite evidence that certain abdominal injuries are highly suspect as being due to abuse [ 131. Knowledge of the force required to cause an injury is often necessary when determining the validity of the history of an injury, yet few studies have provided this information [ 14, 151. The type of injury may be influenced by the age of the child [ 16, 171.The type of injury may also indicate that the child is in jeopardy for further abuse; a trend, from minor soft tissue injuries progressing in time to more serious fractures and finally to fatal head injuries, has been reported [ 181. Despite an extensive array of articles about child abuse [19, 201 and a text devoted to medical aspects of abuse [21], evidence persists which indicates that the medical diagnosis of child abuse is not routinely considered or documented in the medical records of patients with traumatic injuries [22]. The severity, types and anatomic locations of injuries, and ages of children injured may vary with the population being studied. Although abused children who are hospitalized represent a small portion of the total number of battered children, many of the large studies of abuse injuries originate in hospitals where referral patterns and special services, such as a bum unit, and the sophistication and training of the examining staff affect recognition and reporting. Varying definitions of abuse may also affect the reported “incidence” [23]. Patterns of injuries may also vary by county and country depending on reporting laws, definitions and populations served and studied [23-261. A further impediment to our understanding of the patterns of injuries in NAI is the referral of injuries to specialists such as neurosurgeons [27] and pedodontists [28]. Although patterns of inflicted fractures [29] and bums [30] have been studied, patterns of bruises, which appear to be the most common form of child abuse, have received little attention. In order to heighten suspicion of NAI, more details are needed about the causes of all NAI injuries and possible variations which may be influenced by characteristics in the child and abuser. We hypothesized that the type of injury, organ injured and instruments used to abuse a child vary with the age, race and sex of the abused child. Setting for the Study

The Children’s Hospital of Columbus, Ohio, a 313-bed private and non-profit hospital located in metropolitan Columbus, houses the Department of Pediatrics for the Ohio State University. In 1980, the hospital had 45,000 emergency room visits and 14,374 admissions. The hospital admissions of males was 56%. Admissions of whites (84.4%) outnumbered blacks ( 14.1%), Mexicans (. 1%) and Orientals (. 1W). The Child Abuse Team (CAT) evaluated 700 to

Injury variables in child abuse

209

800 children each year between 1978 and 1983. In 1982-1983, 777 children were evaluated: 523 of those were subsequently reported for suspected abuse or neglect; 108 children were admitted to the hospital; and 7 children died. Children who are evaluated by the Child Abuse Team for NAI are generally referred from outside sources to the emergency room with a diagnosis of suspected abuse. In 1982-1983 only 5% were directly referred by outside physicians; 23% were initially seen in the hospital for other reasons. The community cooperation plan and referral patterns encourage the referral of more seriously abused children to Children’s Hospital. The social history is obtained by a CAT social worker. Standardized reporting forms are used to collect the data and transmit it to appropriate agencies. The reporting forms, which include anatomic charts, were used as the data source for this study.

METHODOLOGY Populationstudied A total of 631 reports of suspected physical abuse were reviewed. These reports were completed for children seen during 25 consecutive months in the years 1980-82. Fifteen of the reports were unusable. Procedure Demographic variables such as sex, race, and age of the child, age of the perpetrator, and relationship of the perpetrator to the victim were obtained from the hospital’s abuse reporting forms. This information was cross-checked by the investigators to assure inter-observer reliability. Types, causes, and locations of injuries were assessed as primary (most serious) or secondary by a single investigator. StatisticaiAnalysis Frequencies were computed for 10 types, 14 causes, and 21 body locations of primary injuries resulting from physical abuse. The age, sex, and race of the victim were utilized as independent variables in &i-square analyses [31]. Since there were only 13 victims of mixed race, those cases were combined with blacks for the purposes of comparison by race. xerographic

Variabie~

The sample included 343 boys (56%) and 273 girls (~%). A &i-square analysis of physically abused children by sex of the victim indicated that boys were significantly more likely to be referred for abuse than girls (x2 = 7.94; df = 1; p < .005). The racial distribution was 361 white (59%) 242 black (39%) and 13 mixed (1.3%). The mean age of the children was 7.02 years; the mode was l-3 years; and the median was 4-5 years, with a range of 4 weeks to 17 years. Black children were more frequently evaluated for abuse (36%) than would be expected from their general admission rate to the hospital (14.1%) and population distribution, under 18 years of age in Franklin County (19%) (x2 = 178.22, df = 1; p < .OOl). Of the 616 victims, 121 (20%) were admitted to the hospital, with 8 (1.3%) deaths secondary to their injuries. Of the victims, 151 (25%) had non-healed injuries of different ages, suggesting the possibility of chronic abuse or neglect. For the 616 cases studied, there were a total of 693 perpetrators. Ages were identifi~ for 368. The median age for perpetrators was 25, with a range of 4 to 66 years. The most common

Charles Felzen Johnson and Jacy Showers

210

Table 1. How Injuries Vary with Ace and Race Child’s Age

Infant to 4 Years

4-12

8-17

Highest Risk Type

Highest Risk Cause

Highest Risk Location

Broken Bones Hemorrhage Bums -

Hot Liquid Grid/Heater Iron

Erythema and Marks -

Cord Belt/ Strap Foot Fist Foot Fist

Skull Brain Feet Genitalia Buttocks Hips No Significant Differences

12-17

Lacerations Pain-Tenderness Swelling

Blacks

Lacerations Erythema

Whites

Bruises

Scalp Nose Neck AMlS Thighs

Cord Belt/Strap Switch/Stick Knife Iron Board/Paddle Ooen Hand

Buttocks Face

perpetrators were the mother (28%) and the father (17%). Of the perpetrators was known, 49% were female, and 51% were male.

for whom sex

Type of Injury

Table 1 summarizes the statistically significant differences found for types, causes, and body locations of child abuse injuries in this study. The most common primary injury was bruising (56%) (Table 2). Age effects existed for several types of injury. The youngest victims, aged newborn to 2 years, were significantly more likely to have suffered broken bones than those in any other age group (x 2 = 49.05; df = 1; p < .OOOl).Children from birth to age 3 years were at highest risk for injuries reported as hemorrhage (x2 = 16.68; df = 1; p < .OOl). Bum injuries were also most frequently seen in the youngest age groups; 63% of all bums were suffered by 1 to 3 year olds, who were represented in only 26% of the sample (x2 = 47.08; df = 1; p < .OOl). In contrast, erythema and marks were disproportionately common among children aged 6 to 12 years (x2 = 39.80; df = 1; p < .OOl). Lacerations were significantly more common in children age 12 or older (x2 = 26.3; df = 1; p < .OOl). As might be expected, adolescents were also more likely to report subjective complaints of pain and tenderness, (x2 = 12.49; df = 1; p < .OOl) and swelling (x2 = 11.49; df = 1; p < .OOl) than were children of younger ages. Although only four cases of puncture wounds were reported, all of these occurred in children age 8 or older. Table 2. Primary Injury by Type Type of Injury Bruise/ecchymosis/ hematoma Erythema/marks Bum Abrasion/scratches Fracture/dislocation Swelling Hemorrhage (including internal) Laceration Pain/tenderness (subjective) Puncture

Frequency

Percentage

432 73 59 55 47 40 25 23 17 4

56 9 8 7 6 5 3 3 2
Injury variables in child abuse

211

When race was utilized as the independent variable, significant differences existed in three types of injuries. White children were more frequently diagnosed as having bruises (x2 = 6.13; G” = 1; p < .025), whereas black youngsters were significantly more likely to suffer lacerations (x2 = 10.35; df = 1; p < .005), and erythema or marks (x2 = 10.46; df = 1; p < .005). A comparison of type of injury by sex of the child revealed no significant differences. Cause of Injury A total of 95 different causes were reported as sources of the injuries. The most common known cause of injury was a belt or strap (23%), followed by an open hand (22%) or fist (11 W) (Table 3). Significant age effects existed for types of burn injuries. Forty-one percent of injuries caused by hot liquid occurred in 1 year olds (x2 = 11.78; df = 1; p < .OOl), and 70% occurred in 1 to 4 year olds &* = 11.21; df = 1; p < .OOl). Eighty-two percent of all injuries caused by a grid or heater, and 80% of injuries inilicted by an iron involved 1 to 3 year olds (x2 = 18.53; df = 1; p < .OOl; x2 = 7.84; df = 1; p < -01). Children ages 4 to 12 years, who made up 34% of the sample, were significantly more likely to be struck by a belt or strap than those younger or older w = 78.26; df = 1; p < .OOl); and those 6 to 12 years of age (2 1% of sample) incurred a disproportionate number of injuries from the use of a paddle or board ($ = 20.19; df = 1; p < .OOl). Ninety-five percent of all cord injuries were inflicted on children 5 years of age or older (x2 = 18.58; df = 1; p < .OOl); 6 to 10 year olds were at highest risk (x2 = 14.8; df = 1; p < .OOl). Injuries caused by the foot were significantly more common among children 8 years and older k2 = 10.63; df = 1; p < .OOl), and 70% of injuries caused by the fist were perpetrated against 10 year olds and older (x2 = 58.5; df = 1; p < .OOl). In those cases in which the cause of injuries was unknown, children under the age of 3 were significantly more frequently involved (x2 = 168.85; df = 1; p < .OOl). A comparison of cause of injury by sex of the child revealed no significant differences for belt, paddle/board, fist, hot liquid, switch/stick, propulsion, grid/heater, cigarette, or cord. However, girls were significantly more likely than boys to suffer injuries by an open hand (x2 = 6.9; df = 1; p < .Ol). Significant race effects existed for causes of injury. Black children were more likely to be struck by a belt or a strap k2 = 19.53; df = 1; p < .OOl), or a cord (x2 = 27.49; df = 1; p < .OOl) than were whites. A marginally signiticant difference existed between blacks and whites for injuries incurred by a switch or stick; blacks were more frequently struck with Table3.

PrlmaryhjwybyGme

Known Cause of Injury

1 Belt/strap ;: Hand open (choked, grabbed, pinched, slapped) 3. Fist 4. Propelled (thrown, dropped, pushed, pulled, dragged) 5. Other (e.g., hit by toy, telephone, kitchen fork, bottle, household item, etc.; shot with gun; dunked in ice water, etc.) 6. Switch/stick 7. Paddle/board 8. Cord 9. Hot liquid 10. Foot 11. Grid/heater/stove 12. Cigarette 13. Shoe 14. Knife 15. Mouth 16. Shaking 17. Iron Nore: Cause unknown = 157 (23% of total).

Frequency 124 120 60 41 41 33 32 19 17 11 11 8 5 4 4 3 3

Percentage 23 22 11 8

1 1

1 :1

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212

Table 4. Location of Injury Buttocks/hips Face Arms Back Thighs

Legs Head exterior/scalp Eye Chest Abdomen Hand/wrists Neck Shoulders Ear Feet External genitalia/groin/perineum Nose Mouth Skull Brain/skull contents Rectum Teeth Kidney/bladder

Primary Injury by Location Frequency 169 165 150 147 127 III 108 12 66 57 51 43 38 27 24 23 20 20 13 13 4 2

I

Percentage I?

11 10 IO 9 8 7 5 5 4 4 3 5 2 2

I 1

1 <
these implements (x2 = 3.78; df = 1; p < .lO). Black youngsters were also more commonly knifed (x2 = 4.33; df = 1; p < .05), and more often burned by an iron (x2 = 7.07: df = 1; p < ,025). By contrast, white children were more commonly struck with a board or paddle (x2 = 14.33; df = 1; p < .OOl), and hit with open hand (x2 = 9.19; df = 1; p < .005). For the 157 cases in which cause of injury was unknown, whites were significantly more likely to be victims (x2 = 12.71; df = 1; p < .OOl). Location of Injury

All areas of the body are at risk for injury in child abuse. The most common site of primary injury among the victims of child abuse in this study was the buttocks or hips (12%) followed closely by the face (1 I%), arms (lo%), back (10%) thighs (9%) legs (8%), and scalp (7%) (Table 4). When categories are combined, 33% of primary injuries occurred around the head and face; 35% were inflicted on the trunk and arms; and 32% occurred on the lower body. Children less than one year of age were at significantly higher risk for injuries to the skull (x2 = 12.18; @ = 1; p < .OOl), and to the brain (x2 = 12.18; df = 1: p < ,001) than were other children. Children 1 to 3 years of age were more frequently reported for injuries to the feet (x2 = 7.75; df = 1; p < .Ol), and those aged 2 to 4 years suffered a significantly higher number of injuries to the genitalia than other groups (x2 = 5.77; df = 1; p < ,025). Two year olds were at highest risk for injuries on the buttocks and hips (x2 = 15.34; df = 1; p < ,001). In contrast, children 12 years and older were more likely to suffer injuries to the scalp (x2 = 12.49; df = 1; p < .OOl), nose (x2 = 6.41; df = 1; p < .025), and neck (x2 = 11.85; df = 1; p < .OOl). Chi-square analyses of injuries to 23 different locations on the body revealed no significant differences between boys and girls. Racial differences existed for four locations on the body. White children were significantly more frequently injured on the face (x2 = 4.35; df = 1: p < .05), and the buttocks or hips (x 2 = 4.03; df = 1; p < .05). Black children suffered a disproportionate number of injuries to the arms (x2 = 9.19; df = 1; p < .005). and the thighs (x2 = 6.01; df = 1; p < .025).

Injury variablesin child abuse

213

DISCUSSION Although one might expect that discipline of a more gentle nature would be meted out to girls, the study indicated that the sex of the child did not influence the type of injury suffered. The seriousness of the physical abuse seen at Children’s Hospital was amplified by our findings that 20% of the youngsters required admission to the hospital, and eight deaths occurred secondary to their injuries. This may limit the application of our findings to children who are seen in a hospital setting. One of four children had non-healed injuries of different ages: This suggests chronic maltreatment and is of concern since it has been estimated that an abused child who is returned to his/her parents without intervention has a 50% chance for reabuse and a 10% chance of being fatally injured [32]. Because the ages of injuries were not documented on all abuse forms reviewed for this study, it is possible that the actual chronicity of abuse was higher. Preschool children constituted over half (53%) of this sample, with 1 to 3 year olds at highest risk. The incidence of abuse of preschoolers may be even higher than reported since preschool children are not sufficiently verbal to tell someone about the maltreatment and are isolated in the care of the perpetrators. Reasons why 1 to 3 year olds suffer higher abuse rates may include their physical vulnerability, complete dependency, and caretaker frustration over conflicts of will involving exploration, sleep, feeding, and toilet training. For example, the higher incidence of hot water bums and genitalia injuries to young children may be related to parental frustration over toilet training and ready access to hot water during diaper changing [S]. The relative delicacy of the younger child’s anatomy and his/her inability to evade injury may explain the higher incidence of bum, hemorrhage, and fracture injuries in the very young. The finding that infants O-12 months have a higher incidence of injuries to the skull and brain may be due to their anatomic and structural susceptibility to injury from impact and shaking rather than as a result of caretaker selection of a target organ. There may also be a relationship between scalp, nose and neck injuries in early adolescence and the finding that 70% of injuries caused by the fist were perpetrated against children 10 years and older. Adults who strike out at grown children may strike out as if they were assaulting a victim who approximates their own size. The reasons 6-12 year olds are at highest risk for belt, paddle, and cord injuries are speculative, but may be related to general acceptance of corporal punishment as appropriate discipline for elementary school-age children. Caretakers may believe that an instrument is necessary to inflict adequate pain upon the older child. Race was a significant variable in the type of injury inflicted on the abused child. In 1979-1982, the County Children’s Services abuse evaluation rate of 39.3% for blacks and other non-whites was similar to the findings in this report of 40%. This is in contrast to the findings in one Kentucky study in which whites were over-represented when compared to a control population [33]. One may speculate that our findings that black children suffered more lacerations and more erythema or marks is related to higher usage among blacks of knives, cords, straps, and belts. It is also possible that the higher incidence of buttock and facial injuries of whites may be related to increased usage of boards, paddles and open hands in abusive episodes. Bruises, which were less frequent in blacks, are obscured by the child’s dark skin color. Because bruises were the most commonly reported injury and potentially less disfiguring than the other types of injuries, it is possible that, even with the relatively higher incidence of black children compared to white children being evaluated at Children’s Hospital, bruised black children may be escaping early detection. The wide range of instruments used to abuse suggests that serendipity is a factor in choice of implements The object available at the moment a parent or caretaker loses control may be used to vent anger. However, the findings that black children were more often abused with belts and cords, while white children were more frequently hit with boards or slapped with

Charles Felzen Johnson and Jacy Showers

214

the hand may suggest strong subcultural or racial differences in approaches to discipline. The influence of culture on instruments used to abuse children is supported by a study of abused German children [34]. Implements commonly reported in their study included ladles, wooden shoes, shoe horns, bottle brushes and wire brushes. It is possible that attempts to prevent child abuse by limiting spanking as a form of discipline may result in the substitution of more ominous and dangerous instruments. It is not practical to attempt to decrease the incidence of physical injury by limiting access to dangerous instruments. In this study, just about every common household object was used as a method of expressing anger or frustration toward a child.

IMPLICATIONS

AND CONCLUSIONS

Demographic variables will influence the results of any study coming from an institution such as a children’s hospital. In addition, the level of referral source awareness of child abuse and the referrals of more seriously abused children to the hospital may have influenced the spectrum of injuries reported. To facilitate primary and secondary prevention, professionals dealing with children must be aware of the wide variety of instruments used to discipline children and the influence of age and race of the child on the manifestations of child abuse. Improved professional sensitivity, suspicion and diagnostic acumen, resulting in early recognition of more subtle manifestations of child abuse should decrease the number of children being seen with chronic and more serious injuries. However, motivation to report is also necessary. Professionals should realize that early detection should avail the child of protection from further injuries and offer the parents the opportunity to receive therapy before more serious and possibly permanent injuries to the child’s body or psyche occur.

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