Clinical Review

Identifying Child Abuse

Clinician Reviews. 2012 March;22(3):29-36

References

1. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2009 (2010). www.acf.hhs.gov/programs/cb/pubs/cm09. Accessed February 22, 2012.

2. UNICEF Child Protection Strategy (2008). www .unrol.org/files/CP%20Strategy_English.pdf. Accessed February 22, 2012.

3. World Health Organization. Child maltreatment: Fact Sheet #150, August 2010. www.who .int/mediacentre/factsheets/fs150/en/index.html. Accessed February 22, 2012.

4. World Health Organization. Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence. http://whqlibdoc.who.int/publi cations/2006/9241594365_eng.pdf. Accessed February 22, 2012.

5. Giardino AP. Child maltreatment: is the glass half full yet? J Forensic Nurs. 2009;5(1):1-4.

6. Barriere D. Child abuse: history, laws and the ASPCA (2005). www.resourcesforattorneys.com/childabuseandtheaspcaarticle.html. Accessed February 22, 2012.

7. The Child Abuse Prevention and Treatment Act, Including Adoption Opportunities and the Abandoned Infants Assistance Act, as Amended by the Keeping Children and Families Safe Act of 2003. www.acf.hhs.gov/programs/cb/laws_policies/cblaws/capta03/capta_manual.pdf. Accessed February 22, 2012.

8. H.R. 14: Keeping Children and Families Safe Act of 2003. www.govtrack.us/congress/bill.xpd ?bill=h108-14&tab=summary. Accessed February 22, 2012.

9. S. 3817: CAPTA Reauthorization Act of 2010. www.govtrack.us/congress/bill.xpd?bill=s
111-3817. Accessed February 22, 2012.

10. National Data Archive on Child Abuse and Neglect. NCANDS State Level Data 2009: National Child Abuse and Neglect Data System. www .ndacan.cornell.edu/cmrlpostings/msg00195.html. Accessed February 22, 2012.

11. Finkelhor D, Jones L, Shattuck A; Crimes Against Children Research Center, University of New Hampshire. Updated trends in child maltreatment, 2009. http://unh.edu/ccrc/pdf/Updated_Trends_in_Child_Maltreatment_2009.pdf. Accessed February 22, 2012.

12. CDC Injury Center: Violence Prevention. Child Maltreatment: Risk and Protective Factors (2011). www.cdc.gov/violenceprevention/childmaltreat ment/riskprotectivefactors.html. Accessed February 22, 2012.

13. Sullivan P, Knutson J. Maltreatment and disabilities: a population-based epidemiological study. Child Abuse Negl. 2000;24(10):1257-1273.

14. Sedlak AJ, Mettenburg J, Basena M, et al. Fourth National Incidence Study of Child Abuse and Neglect (NIS–4): Report to Congress, Executive Summary. January 2010. Washington, DC: US Department of Health and Human Services, Administration for Children and Families.

15. National Clearinghouse on Family Violence, Public Health Agency of Canada. Abuse of children with disabilities (2000). www.phac-aspc
.gc.ca/ncfv-cnivf/pdfs/nfnts-disabl-eng.pdf. Accessed February 22, 2012.

16. Endorm EE. (2011, June 7, 2011). Physical abuse in children: epidemiology and clinical manifestations. www.uptodate.com/contents/physical-abuse-in-children-epidemiology-and-clinical-manifestations?source=search_result&
search=Phsical+abuse+i+children%3A+Epidemiology+and+clinical+manifestations&selectedTi
tle=1~150. Accessed February 22, 2012.

17. Pandya NK, Baldwin K, Kamath AF, et al. Unexplained fractures: child abuse or bone disease? A systematic review. Clin Orthop Relat Res. 2011; 469(3):805-812.

18. Gondim RM, Muñoz DR, Petri V. Child abuse: skin markers and differential diagnosis. An Bras Dermatol. 2011;86(3):527-536.

19. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ. 2008;337:a1518.

20. Worlock P, Stower M, Barbor P. Patterns of fractures in accidental and non-accidental injury in children: a comparative study. Br Med J (Clin Res Ed). 1986;293(6539):100-102.

21. Welsh Child Protection Systematic Review Group. www.core-info.cf.ac.uk. Accessed February 22, 2012.

22. Wardinsky TD. Genetic and congenital defect conditions that mimic child abuse. J Fam Pract. 1995;41(4):377-383.

23. American College of Radiology. ACR appropriateness criteria (2009). www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/Suspected PhysicalAbuseChildDoc9.aspx. Accessed February 22, 2012.

24. Meservy CJ, Towbin R, McLaurin RL, et al. Radiographic characteristics of skull fractures resulting from child abuse. AJR Am J Roentgenol. 1987;149(1):173-175.

25. US Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Burn Injuries in Child Abuse (2001). www.ncjrs.gov/pdffiles/91190-6.pdf. Accessed February 22, 2012.

26. Lane WG, Dubowitz H. Primary care pediatricians’ experience, comfort and competence in the evaluation and management of child maltreatment: do we need child abuse experts? Child Abuse Negl. 2009;33(2):76-83.

27. Child Welfare Information Gateway, US Department of Health and Human Services, Administration for Children and Families. Recognizing child abuse and neglect: signs and symptoms (2007). www.childwelfare.gov/pubs/factsheets/signs.cfm. Accessed February 22, 2012.

28. Fortin K, Jenny C. Sexual abuse. Pediatr Rev. 2012;33(1):19–32.

29. Keshavarz R, Kawashima R, Low C. Child abuse and neglect presentations to a pediatric emergency department. J Emerg Med. 2002;23(4): 341-345.

30. Kellogg N; American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics. 2005;116(2):506-512.

31. Heger A, Ticson L, Velasquez O, Bernier R. Children referred for possible sexual abuse: medical findings in 2384 children. Child Abuse Negl. 2002;26(6-7):645-659.

32. Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: “normal” does not mean “nothing happened.” Pediatrics. 2004; 113(1):e67-e69.

33. Workowski KA, Berman S; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1-110.

34. Oates RK. Overturning the diagnosis of child abuse. Arch Dis Child. 1984;59(7):665-666.

35. Hornor G. Common conditions that mimic findings of sexual abuse. J Pediatr Health Care. 2009;23(5):283-288.

36. Asnes RS. Buttock bruises: Mongolian spot. Pediatrics. 1984;74(2):321.

37. Klusmann A, Lenard HG. Tourniquet syndrome: accident or abuse? Eur J Pediatr. 2004; 163(8):495-498.

38. Merten DF, Carpenter BL. Radiologic imaging of inflicted injury in the child abuse syndrome. Pediatr Clin North Am. 1990;37(4):815-837.

39. Mok JY. Non-accidental injury in children: an update. Injury. 2008;39(9):978-985.

40. Nelson CS, Higman SM, Sia C, et al. Medical homes for at-risk children: parental reports of clinician-parent relationships, anticipatory guidance, and behavior changes. Pediatrics. 2005; 115(1):48-56.

41. Dubowitz H. Prevention of child maltreatment: what is known. Pediatrics. 1989;83(4):570-577.

An observation of unusually sexualized behaviors or a report of excessive masturbation is more likely to be associated with sexual abuse than are genital findings (which are infrequently found).

Physical Examination

When a child presents with an acute injury or bruising is detected and the clinician’s findings are inconsistent with the given history, suspicion should be raised. The injuries inflicted by physical abuse are often hidden beneath the child’s clothing (specifically, underwear); for this reason, it is important to have children undressed during a physical exam.

The routine physical exam of an abused child may reveal defensive bruising or other wounds, trauma to the mouth, breasts, buttocks, genitalia, or anus, with possible bleeding or discharge. More commonly, the physical exam findings are normal—as is true in the majority of examinations for sexual abuse.³⁰ In one large study, abnormal findings (eg, recent or healed genital injuries; presence of a sexually transmitted disease) were found in only about 4% of children who had been referred for an examination for suspected sexual abuse.^18,31 Clearly, an appearance of “normal” does not mean “nothing happened.”³²

According to CDC guidelines,³³ investigation of suspected sexual abuse (for example, when a genital herpes infection is detected) should be conducted by appropriately trained, experienced clinicians—ideally, by a pediatric subspecialist in child abuse. Although the primary care clinician may examine the child briefly for visible bruises or wounds, it is essential for a specialist to perform the genital exam.³³ Use of mild sedation with close monitoring may be advisable during the genital examination.³⁰

Mimics of Child Abuse

Several conditions, including metabolic, genetic, and congenital disorders, have been reported to mimic the physical manifestations of child abuse and neglect^17,22,34 (see Table 4,^{17,18,22,25,33-35}). While health care professionals are legally and ethically bound to report abuse, conditions that may mimic abuse must be ruled out first, to avoid the mistaken removal of children from loving homes.

Mongolian spots, for example (see Figure 2), are frequently mistaken for bruising and reported to authorities, causing unnecessary disruption for both family and child.^34,36 They typically appear as macular blue-gray pigmentation of the skin, usually on the sacrum. Resulting from entrapment of melanocytes in the dermis during fetal development, these “spots” may be present at birth or may appear during the neonatal period. Mongolian spots are most common in Native American, African-American, Asian, and Hispanic patients, are benign, and often disappear by age 4.

Other cutaneous manifestations that can mimic an intentional injury include molluscum contagiosum, a viral infection manifesting as a rash that may mimic the genital warts of human papillomavirus, and erythematous, edematous, and/or vesiculobullous lesions^18,35 (see Figure 3). Severe diaper rash, photodermatitis, and certain allergic reactions can mimic intentional burns.²⁵

Often mistaken for a nonaccidental injury is hair tourniquet syndrome—the circumferential strangulation of one or more appendages (eg, finger, toe, penis) by human hair or fibers.³⁴ This uncommon condition, usually unintentional and of unknown incidence, can represent a surgical emergency; failure to recognize it in a timely fashion may lead to ischemia or necrosis, necessitating amputation of the affected appendage.³⁷

Metabolic bone disease, such as osteogenesis imperfecta, can sometimes explain frequent fractures.¹⁷

MAKING THE DIAGNOSIS

In the primary care setting, the detection of child abuse is unexpected. However, it is often here that children are initially seen for an injury, or suspicions are raised during a routine physical.³⁰ In the case of spontaneous disclosure of abuse, explicit, word-for-word documentation is required. The child, who may feel guilty, embarrassed, or ashamed, must be reassured that he or she is not at fault.

Either a child abuse specialist or the primary care clinician bases the ultimate diagnosis of child abuse on findings from the history and physical examination. These findings will direct the clinician’s decision to order diagnostic laboratory studies and/or diagnostic x-rays.

Diagnostic Studies

Depending on the child’s age and the type of presentation, recommended imaging studies include an x-ray skeletal survey of a child younger than 2 (see “Skeletal Survey Reading of 5-Month-Old Boy,”) or an older child with thoracoabdominal injuries that the history does not explain satisfactorily.²³ For children ages 2 to 5, focused plain films of the area of suspected injury (eg, skull, chest, extremities) are considered appropriate.^23,38

Noncontrast head CT may be appropriate in the presence of skull fractures, (as in Figures 4a and 4b) intracranial injuries, seizures, or other neurologic signs and symptoms (followed by MRI if further assessment is needed). CT with contrast may be considered when x-rays reveal certain abnormalities, the child is considered at high risk for abuse (for example, when inconsistencies are found in the history), or when soft-tissue injuries are suspected.^23,39