The abuse and neglect of children II: Recognizing child abuse

The Abuse and Neglect of Children II: Recognizing Child Abuse

ELSEVIER

Susan ]. Woolford, PEDIATRICS/HUMAN

Pediatrics

Update

Abstract

PSYCHlATRlSTS

UNIVERSITY,

DEVELOPMENT, EAST

LANSING,

D. Rappley, COLLEGE

2;4:90-93,1997.

0 1997 Elseular Sc&nce ISSN 1022~7278/97/Sl7.00 PII sllm2-757q27jmlO28-9

Inc.

MD OF

HUMAN

MEDICINE,

MICHIGAN

MICHIGAN

Introduction

Child abuse is a highly signifkant probkm fw children and their families. Almost three million reports of child abuse -filed in 1992; 65% of these were substantiated. This is the second in a series of three articles regarding abuse. The first, “The Abuse and Neglect of Children,” published in the last edition of Medical Update fm Psychiatrists, describe5 the epidemiology of abuse, char. . actemtws of high-risk victims and perpetrators, and impm-tunt kisuea regarding the reporting of abuse and interacting with families. This second article focuses on recognizing child abuse. The haibnarh of intational, abusive injury to a child is a dkcrepant history, unreasonable given the age of the child and the nature of the wound or circumstances surrounding the injury. Spea@ injuries such as fkzctures, bruises, burns, and blunt trauma may have characteristic patterns suggesting abuse. Neglect is the failure of the caregiver to provide fm adequate child care in health, education, su+, and physical needs of the child. Munchausenbyproxyisthediagnosisgiven tx3deceptivea&mt4zkenbyaparentto simulate illness in a child, that is detrimental to the child and fm which secondary gain is derived by the parent in the medical process. Sexuul abuse will be the subject of the third and lust art& de, which is to follow in the next issue of Medical Update fm Psychiatrists. An awareness of the classic features of child abuse will help the physician rewpize abuse, and thus may protect a child fimn&rther abuse and provide a family with badly needed services. 0 1997 Else&r %ience Inc. MEDICAL UPDATE FOR

STATE

MD and Marsha

Case Vignette A e-year-old white male is brought to the emergency department by his mother with scald bums on his lower extremities. The patient’s mother states that while feeding her 7-day-old daughter she heard her son crying. She ran into the bathroom and found him sitting on the countertop with his feet in the sink and the hot water running. She states she quickly turned off the hot water, turned on the cold water, and then called 911. Physical examination reveals third-degree bums on both lower extremities extending from his feet to the mid calf. The borders appear circumferential with rare splash marks. The flexor creases of the ankles and the balls of his feet are spared. No other bruises, burns, or scars were noted. Child abuse is a highly significant problem for children, their families, and the physicians who encounter them. Almost three million reports of child abuse were filed in 1992; 65% of these were substantiated (1). This is the second in a series of three articles focusing on recognizing child abuse (2). The hallmark of intentional, abusive injury to a child is a discrepant history, which is unreasonable given the age of the child and the nature of the wound or circumstances surrounding the injury. Specific injuries such as fractures, bruises, bums, and blunt trauma may have characteristic patterns suggesting abuse. Neglect is the failure of the caregiver to provide for adequate child care in health, education, supervision, and physical needs of the child. Munchausen by proxy syndrome is the 1 and only diagnosis given to deceptive action taken by a parent to simulate illness in a

Address reprint requests to: Marsha D. Rappley, MD, College of Human Medicine, Michigan State University, Department of Peds/Human Development, B240 Life Sciences, East Lansing, MI 48824.

child that is detrimental to the child and for which secondary gain is derived by the parent in the medical process. Sexual abuse will be the subject of the third and last article, which is to follow in the next issue of Medical Update for PSYchiatrists. An awareness of the classic features of child abuse will help the physician recognize abuse, and thus may protect a child from further abuse and may provide a family with badly needed services.

The Importance

of the History

The history is vital to recognizing abuse. The cardinal sign of intentional injury is the discrepant history. There may be no explanation offered for the chiId’s injury, or there may be a partial history that doesn’t explain how the injury occurred. The history may be inconsistent with the nature of the injury, for example a fall from a couch onto a carpeted floor resulting in a skull fracture. The history may change over time or with each telling. The history may not be appropriate to the developmental age and abilities of the child. The story may not be consistent with a reasonable reaction of a child in pain. There may be a delay in seeking medical help (1,3,4). In the Case Vignette, for example, the mother maintained that the child must have turned on the hot water by himself and placed his feet into scalding water. There are many discrepancies here. A 2-year-old child may not have the ability to manipulate a round-handled water faucet. A child mistakenly putting feet into scalding water would attempt to get out, causing splashes that would leave an uneven rather than clearly demarcated circumferential bum. The balls of the feet and the flexor creases of the ankles of this child were spared. The child would not willingly press his feet onto the sink, thereby sparing the balls of the feet from bum, nor maintain a posture with the ankles flexed so tightly that the creases would

MEDICAL

UPDATE

FOR PSYCHIATRISTS

be spared from scalding. Rather, this is a pattern of a bum inflicted by someone intentionally holding the child’s feet and legs in scalding water. The history as related by the caregiver must be carefully documented. Every attempt should be made to obtain a detailed description of the event. If more than one person was present, it may be helpful to obtain each person’s account of what occurred. If the patient is old enough to be interviewed, every effort should be made to make them as comfortable about sharing their story as possible, avoiding leading questions or the sense that anyone is being accused of wrongdoing. However, this must be done while keeping in mind that the family should be spared unnecessary retelling of the story. In addition, the more “history takers” involved, the more likely there will be differences in what is described that may later be used in defense of an accused perpetrator. The importance of a multidisciplinary team, a child protection team, or referral to a specialist in examination for child abuse cannot be overstated. HOWever, if the physician encounters the first disclosure of possible abuse, the history must be carefully taken and recorded, the immediate safety of the child assessed, and notification to a child protection services agency must be made. The first article discusses the difficulties of this process and provides information that may be of help (2,5,6). The social history may reveal stressors and family dynamics associated with abuse and should therefore be included in the history taking. Abuse OCcurs without regard to social, economic, or ethnic background. Factors that place parents and children at risk are discussed in the first article and listed in Table 1 of this article. The risk for child abuse is compounded by any combination of risk factors, unrealistic expectations of the child, and an impulsive adult (1,3,4).

The Physical

Examination

The interaction between the child and parents should be assessed during the examination process. Harsh, angry interactions should be considered a red flag. However, children who live with abuse may feel a strong attachment even to an abusive parent. The follow-

The Abuse and Neglect of Children

Table 1. Risk Factors for Child Abuse Social Circumstances Crisis in the household Isolation of the family Limited access to community institutions Violence in the community Poverty associated with any other risk factor High-Risk Features of Parents Unrealistic expectations of the child Alcohol or substance abuse Personal crisis of the parent Spousal abuse Mental illness High-Risk Features of the Child Younger age, especially less than 5 years Mental retardation Handicapping condition Chronic illness Prematurity Colicky baby Behavior problems

ing are descriptions patterns of abusive,

of classic intentional

physical injury.

Bruises Bruises are the most common sign of abuse. Children often sustain accidental bruises in the course of normal play, however, these are usually on the bony extensor surface of the forearm and the legs or on the forehead. Bruises on the medial aspects of the legs or other unusual places are more suspicious. The color of bruises may suggest multiple bruises at different stages of healing (1). It is sometimes possible to determine the instrument used to inflict an injury by the characteristic pattern of the resulting bruise. The finger marks of an open-handed slap or the imprint of knuckles from a punch may be evident. Other objects that leave identifiable marks are buckles, a looped cord, clothes hangers, brushes, sauce pans, spatulas, or spoons. Bruises, abrasions, and lacerations may be apparent from a cord used to restrain the child’s arms or legs. Strangulation marks and bite marks also have characteristic patterns. Hair pulling may present with patches of hair loss and hair that is broken at various lengths (3).

Fractures Fractures at various stages of healing are suggestive of intentional injury. This

may be apparent from a radiologic skeletal survey obtained in order to investigate the possibility of fractures when other signs of abuse are present. A classic finding in abuse is a chip fracture in which the comer of the metaphysis of a long bone is tom off, with resultant damage to the epiphysis and the periosteum. If an infant is squeezed aggressively, multiple rib fractures and scapular fractures may result. Spiral fractures are suggestive of wrenching and pulling. Fractures of the spinous processes suggest abuse as well (3).

Burns Burns are secondary to abuse or neglect in 10% of cases. They account for up to 28% of all cases of maltreatment of children (1). The most common type of intentional bums are scald burns. However, bums secondary to matches, cigarettes, lighters, and heating devices such as irons may also be seen. The presence of a full-thickness, sharply demarcated or symmetrical bum on the buttock, perineum, genitalia, or distal aspect of the limb should alert the examiner to the likelihood of abuse. This category includes burns with a stocking or glove distribution without splash marks, as in the Case Vignette. In a similar fashion, a characteristic donutshaped scald on the buttocks is formed when a child is held by the torso and legs and immersed in hot water; because the buttocks are pressed against the tub or sink, the central region of the buttocks is spared from bum due to contact with the bottom of the tub or sink (3). Several bum injuries present with the pattern of the object readily discernible. Cigarette bums, when due to an inflicted injury, usually appear sharply demarcated and deep. Often the shape of an iron or hot grill may be seen when these objects have been used as the weapon. Curling iron bums are very common. If caused accidentally, these bums will have a glancing pattern consistent with the object falling onto the body, or will be a bum of the palmar surface of the hand, consistent with a young child grasping the hot object. Intentional bums have sharp borders and a depth consistent with applied pressure.

S. J. Woolford

Head

and

M. D. Rappley

Trauma

Head trauma is the most common cause of death from child abuse. The presentation may include coma, seizures, apnea, or increased intracranial pressure. A blow to the head inflicted by a hand may cause subdural hematoma but leave no external indicator of injury. Retinal hemorrhages are associated with shaken baby syndrome and are the result of an accelerationdeceleration injury. While a history may be given of a fall, a fall of less than four feet is unlikely to cause a skull fracture and there are no reports of death or severe brain injuries from witnessed falls of less than ten feet (1). Intra-Abdominal

Injuries

Intra-abdominal injuries are the second most common cause of death from child abuse. The presentation may include vomiting, distention of the abdomen, absent bowel sounds, abdominal tenderness, and shock. There may be a ruptured liver or spleen, duodenal hematoma, or pancreatic contusion. Again, there may be no external indications of injury. Genital

Injuries

Genitalia should be examined carefully for evidence of traumatic injury and sexual abuse. It is not uncommon for abuse to be triggered by toileting accidents, with injury directed to this part of the body. Sexual abuse will be specifically discussed in the third article in this series.

Conditions That May Be Contused with Abuse Many accidents and misadventures of childhood result in injury. Again, the history is critical and must be assessed relative to the child’s age-appropriate developmental abilities and the nature of the injury. Splash, spill, and pour burns may well have a different configuration than an intentionally applied bum. Petechiae of the face may result from retching and coughing. Cardiopulmonary resuscitation only rarely results in fractures or retinal hemorrhage. Other physiologic conditions and disorders that may be confused with abuse are listed in Table 2 (3).

MEDICAL

Table 2. Conditions fused with Abuse

That

May be Con-

Mongolian spots Capillary hemangioma Pigmented nevi Impetigo Coagulopathies Henoch-Schonlein purpura Urticaria pigmentosa Osteogenesis imperfecta

Behavioral manifestations of child abuse include depression, anxiety, anger, poor self-esteem, developmental delays, poor school performance, oppositional and defiant behavior, conduct disorder, and symptoms of posttraumatic stress disorder. Child abuse is appropriately considered in the differential diagnosis of behavior and emotional problems of childhood (1).

Signs of Neglect Child neglect refers to failure of the caregiver to provide adequate child care in health, education, supervision, and physical needs (1,4). The presentation of child neglect varies greatly. A child may appear apathetic. There may be lack of attachment and a lack of developmentally appropriate separation anxiety usually seen at seven to eight months of age and again at approximately eighteen months to two years of age. A child may appear highly anxious, sad, or withdrawn. The child may be hungry or regularly go long hours with no food. There may be inadequate clothing for the weather. The child may frequently be absent from school. There may be poor growth and inadequate, delayed health care. There may recurrent unintentional injury, be which indicates a lack of appropriate supervision. Neglect is not confined to impoverished families. It may be related to extremely unrealistic expectations of children for a given developmental age, so that very young children are left to find their own food and clothing, to make their own way to school, and often left to supervise even younger children. Abandonment is the extreme form of neglect (1,4). Child protection agencies often accept referrals for only extreme cases of neglect. In some states, social services agencies are so overburdened that they

UPDATE

FOR PSYCHIATRISTS

do not accept referrals for child neglect at all. This is despite the fact that approximately half of the children who die from maltreatment die as a result of neglect (4,5).

Munchausen

by Proxy

Syndrome

The diagnosis of Munchausen by proxy syndrome is applied to the child who is ill because the parent, most often the mother, has taken deceptive action to simulate a disorder in the child. Extensive medical evaluation results, often involving invasive procedures and treatments. The measures taken to induce illness can endanger the child (e.g., administering thyroid medication or injecting fecal material). The medical procedures may place the child at risk as well. These procedures tnay be not only invasive diagnostic procedures, but may also include restrictions and treatments that prevent a child from being well. Examples include extensive gastroenterology investigations and hyperalimentation for presumed inability to digest food. The diagnosis is often not made until members of the medical team begin to carefully question why the case seems inexplicable and does not proceed or resolve as expected. The diagnosis requires careful scrutiny of the history and medical record over time and perhaps over the care of many physicians. This disorder is rare, but there is a 10% mortality associated with Munchausen by proxy syndrome (1).

Corporal Punishment and Other Cultural Uarlatlons In the Care of Children Corporal punishment is widely accepted as necessary in raising a child and injuries may be explained as punishment for wrongdoing. An approach recommended by physicians who have expertise in working with abused children and their families is to consider as abuse any injmy beyond immediate redness of the skin. Any violent act directed toward a child is- abuse, whether or not it results in injmy (4-6). There are traditional practices that may be unique to a particular ethnic group that may inadvertently result in injury to the child. Examples of these are coining, in which hot coins are placed on the child’s torso to treat a health problem,

MEDICAL

UPDATE

and cupping, in which suction cups are applied to the skin for a similar purpose. An interpreter may be needed to facilitate communication between the physician and parents in these cases. Injury to a child is not an acceptable outcome of parenting behaviors and parents may need to be counseled about this.

Prognosis Families

The Abuse and Neglect of Children

FOR PSYCHIATRISTS

for Children

and

All 50 states have mandatory reporting laws regarding the abuse and neglect of children. The law provides protection for those who report in good faith. Of cases substantiated, 2 to 3% result in termination of parental rights. Up to 15% of families, especially those with substance abuse problems, require long-term intensive social, medical, and mental health services to meet the needs of the children within the home (1). The majority of families respond to

comprehensive services made available through contact with child protection services. The physician who recognizes child abuse and initiates an appropriate referral may protect a child and enable a family become connected to urgently needed

services

(5,6).

References JohnsonCF. Abuse and Neglect of Children. In: Nelson, Berman, Kliegman, Arvin (eds): Nelson Textbook of Pediatrics, 15th ed. Philadelphia:Saunders, 1996:112-21. RappleyMD. Abuseandneglectof children I: Context of abuseand neglect. Medical Update for 2(3):86-8.

Psychiatrists

1997;

Sirotnak AP, Krugman RD. Physical abuseof children: An update. Pediatr Review 1994;15( 10):394-g. Dubowitz H, Finkel M. Child abuse and neglect.In: HoekelmanRA, Friedman SB, Nelson NM, Seidel HM, We&man ML (eds):Primary pediatric

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care, 3rd ed. St. Louis: Mosby, 1997: 621-6. American Academy of Pediatrics: A guide to referencesand resourcesin child abuse and neglect. Section on Child Abuse and Neglect. Elk Grove, IL: The AmericanAcademy of Pediatrics, 1994. Available by calling l-800433-9016:askfor publications. American Medical Association. Diagnostic and treatment guide physical abuse and neglect. Chicago: AMA, 1992.

Recommended Texts

Photographic

Heger A, Emans SJ. Evaluation of the sexually abused child. A Medical TextBook and Photographic Atlas. New York: Oxford University Press, 1992. Reece RM. Child Abuse: Medical Diagnosis and Management. Philadelphia: Lea & Febiger, 1994.