Child Abuse

Overview

Definition

Child abuse refers to an act or failure to act that results in actual or potential harm to a minor’s health, development, or dignity by the parent or caregiver responsible for the child’s welfare. In the majority of the United States, a minor is defined as a child below 18 years of age, unless emancipated by law.

Classification

There are 4 main types of child abuse:

• Neglect:
  • Inability to meet a child’s physical, medical, or educational requirements
  • Most common type of child abuse
• Physical (battered child syndrome):
  • Intentional injury causing severe pain
    • Impairs physical functioning 
    • May leave a physical mark
  • Examples: burns, beating, shaking, biting
  • Shaken baby syndrome: 
    • Traumatic brain injury secondary to shearing forces when an infant is shaken
    • Results in subdural hematoma or diffuse axonal injury
  • Medical:
    • Also known as factitious disorder by proxy
    • A caregiver falsely presents a child for medical attention by fabricating a history or directly causing a child’s illness by exposing them to a toxin, medication, or infectious agent.
• Sexual:
  • Involvement of a child (< 16 in many states) in sexual activities that they can’t comprehend or consent to
  • Includes sexual activity, fondling, and contact of anal, genital, or oral regions
• Emotional: 
  • An act that would terrorize a child resulting in negative affect and future psychological illness
  • Includes verbal abuse, humiliation, threats of violence, rejection
  • Least reported because difficult to document

Epidemiology

• The WHO estimates (2014): 
  • 23% of children worldwide report being physically abused.
  • 18% of girls and 8% of boys worldwide experience sexual abuse.
  • Infanticide: 2 times greater in low-income compared to high-income countries
• Greater incidence in lower socioeconomic groups, but affects all races, ethnicities, and socioeconomic groups
• Neglect: the most common form of abuse
• Physical: 
  • Usually carried out by primary caregiver
  • Greatest cause of mortality: 70% of victims are < 3 years old.
  • Shaken baby syndrome carries significant morbidity. 
• Sexual: 
  • Peaks in girls aged 9–12
  • Perpetrator usually known to the victim
• Emotional:
  • 80% of victims develop a psychiatric illness in adulthood.
  • Rarely reported in childhood 

Risk factors

• Caregiver factors:
  • History of abuse during childhood
  • Substance abuse
  • Mental illness
  • Domestic violence in the parental relationship
  • Sudden major life crisis (e.g., loss of job or financial security, loss of home, loss of spouse)
  • Emotional and social isolation
• Victim factors:
  • Younger than 3 years old
  • Separated from the mother at birth (impaired bonding)
  • Has a disability, congenital abnormality, or is a colicky infant
  • Child in foster care
  • Perceived as defiant or oppositional
  • Emotional problems
  • ADHD
• Societal factors:
  • Poverty
  • Inability to afford good, high-quality childcare products and services
  • Lack of government support for social welfare programs, healthcare
  • Dangerous neighborhoods
  • Lack of recreational facilities and community activity for children

Clinical Presentation

Failure to thrive is the most common presentation of child abuse. Frequent emergency department visits or a delay in presentation with injuries inconsistent with history are red flags. The following features in history and physical examination increase the likelihood ratio of abuse:

Physical abuse

History:

• Changing or inconsistent events leading to injury, with conflicting accounts by caregivers
• Recurrent “accidents” or injuries and hospitalizations
• Delay in seeking or providing medical care
• Incompatible injury with milestones (e.g., bruising anywhere on a child not crawling or walking)

Physical examination:

• Observation of child–caregiver interaction demonstrating lack of eye contact and apathy
• Old and recent, extensive bruises:
  • In unexposed or unusual areas (e.g., buttocks, genitalia, flexor surfaces, ears)
  • Patterned, usually in the shape of an object (e.g., hand, knuckles, belts, cords, footwear)
• The following fracture sites are highly suggestive of abuse:
  • Posterior aspect of ribs
  • Scapula
  • Spinous processes
  • Sternum
• Bite marks (1 or 2 opposing arches)
• Burn marks:
  • Shape of the inflicting object (e.g., steam iron, curling iron, hot plate, cigarette burns (round marks))
  • Symmetrical pattern with equal burn depth
  • Due to immersion in hot liquids (sparing creases) with clear demarcation
• Abdominal pain
• Oral lesions (e.g., torn frenulum, bruises, fractured dental pieces)

Shaken baby syndrome:

• Retinal hemorrhage
• Lethargic 
• Tense fontanelle
• Seizures

Sexual abuse

History:

• The child’s statement of events is the most important feature. 
• Knowledge of explicit sexual behavior
• Sexual behavior inappropriate for age, such as undressing or touching others’ genitals
• Recurrent urinary tract infections
• Presence of sexually transmitted disease

Physical examination (always done with a chaperone):

• The majority (96%) of cases have a normal anogenital examination.
• Examination has to be done within 24–72 hours of the event (specimen collection).
• Fissuring or tears at the corner of the mouth
• Gingival and palatal contusions
• Contusions, erythema, tears, abrasions, or lacerations of genitals and/or anal sphincter
• Vaginal discharge may be:
  • Seminal secretion
  • Indicative of a sexually transmitted infection
• Condylomata acuminata (CA) (HPV infection)

Emotional abuse

History:

• Poor school performance
• Aggressive, defiant behavior
• Frequent physical complaints

Physical examination:

• Detached from primary caregiver
• Shows signs of low self-esteem, anxiety, or depression

Neglect

History:

• The caregiver is unaware of medical history or lack of follow-up.
• The child is frequently placed in the care of adults with no blood relation.

Physical examination:

• Child unkempt
• Failure to thrive
• Dental caries
• Dehydrated and malnourished
• Extensive diaper rash
• Uncleaned wounds

Mnemonics

Red flags that specify a nonaccidental trauma can be best remembered by the mnemonics TEN-4 and FACES P:

• Bruising: on Torso, Ears, Neck in children aged 4 or younger and any bruising on an infant < 4 months old
• The Frenulum, Auricular area, Cheeks, Eyes, Sclera, and Patterned bruising must be examined in cases of suspected abuse.

Diagnosis

Physicians must have a high index of suspicion in patients with risk factors and red flags as determined from the history and physical examination. To confirm suspicion, a thorough physical examination, including ophthalmological and neurological exam, must be done.

To gather as much information as possible, the physician must:

• Have a non-judgmental approach
• Obtain an organized sequence of events
• Allow the child to recall on their own to avoid implantation of ideas and revictimization
• Lead with open-ended questions that give the child the freedom to retell events as a story at their own pace

Investigation includes:

• A skeletal survey:
  • 21 dedicated views →  anteroposterior (AP) and lateral aspects of the skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest, AP pelvis; AP of each femur; AP of each leg; AP of each humerus; AP of each forearm; posterior and anterior views of each hand; AP (dorsoventral) of each foot
  • Fractures at multiple sites and multiple stages of healing are suggestive of physical abuse.
• Noncontrast CT scan of the head → intracranial /subdural hematoma (shaken baby syndrome)
• Coagulation studies to rule out a bleeding disorder for extensive bruising
• In cases of sexual abuse:
  • Urinalysis
  • Beta-hCG (b-hCG) for pregnancy
  • STD panel

In cases of sexual abuse:

• The child may have difficulty conveying information verbally.
• Consider having the child draw what happened, demonstrate events with anatomically correct dolls, or write about the events.
• Specimen collection must be done:
  • Rape kits commonly used in emergency departments
  • Vaginal or penile secretions
  • Unwashed clothing used after the events
  • Fingernail scrapings
  • Hair samples
  • Blood sample
  • Saliva sample
  • Document with photos and videos as much as possible.
  • Any elements found on the victim, or provided by them, must be packaged and labeled on collection and introduced in the chain of evidence.

Management

Physicians are legally mandated to report all cases to child protective services. Documentation at every step and visit is essential to support suspicion.

Management

• Goal: Remove the child from harm and danger.
• Ensure the patient is stable and all life-threatening injuries are managed.
• In cases of sexual abuse, prophylaxis for STDs, including HIV, within 72 hours of incident
• Multidisciplinary team approach including physicians, pediatricians, nurses, psychologists, psychiatrists, and social workers
• Long-term follow-up is required to ensure the child reaches all developmental milestones and is not suffering from any psychiatric illness.

Prevention

• Physicians may use the SEEK (safe environment for every kid) model to screen caregivers with a questionnaire and guide those with high-risk factors for abuse to appropriate resources, such as pamphlets and community and hospital-based programs.
• Caregivers of children with a chronic medical disease or developmental disability would benefit from anticipatory guidance and closer follow-up.

Clinical Relevance

The following conditions are part of the differential diagnosis of child abuse and must be kept in mind when documenting to report:

• Failure to thrive: suboptimal weight gain and growth in infants and toddlers on standardized growth charts. Although neglect is a major cause, physicians must look for organic causes of lack of weight gain.
• Osteogenesis imperfecta (OI) or brittle bone disease: a spectrum of disorders of connective tissue characterized by impaired bone formation and severe bone fragility. Children with OI classically have a history of fractures during low-impact activities (e.g., diaper change) since birth.
• Ehlers-Danlos syndrome (EDS): a connective tissue disorder that causes easy bruising due to defective collagen production. Presence of hyperextensible skin and hypermobile joints, along with a genetic test, confirms this syndrome.
• Hemophilia: an inherited deficiency of factor 8, 9, or 11 resulting in bleeding within deep tissues that may mimic extensive bruising. Usually, there is no history of minor trauma. Blood work looking for the specific factor diagnoses hemophilia.
• Mongolian spots: a congenital birthmark seen most commonly over the lumbosacral area. Mongolian spots mimic bruising, as they are bluish-green to black in color and usually irregularly shaped. History and follow-up of the spot can differentiate it from a nonaccidental bruise.
• Xeroderma pigmentosum: an X-linked genetic disorder that causes extensive burns to skin exposed to UV light due to the lack of a DNA repair mechanism. Patients usually suffer from extensive sun burns, freckling, and excoriations. 
• Normal anatomical variants of male and female genitalia and of the anal sphincter in young children: includes variants of hymenal configuration, septal remnants, intravaginal ridges, anal fissures, and perianal skin tags (constipation), which may simulate signs of sexual abuse.