So when we see a concerning case of child
abuse, how do we drill down on this?
Well, part of the problem is
that we have to be careful
with the way we ask the child questions.
Depending on the child’s age,
they may change their answer
because of a need to protect the parent
or a feeling of guilt like
they had brought it on.
But also there are clear cases in the
literature of children who have not been abused
with pointed questioning eventually
agreeing that this had happened.
A classic example is of
course the Salem Witch trial
where people were repeatedly
questioned and eventually said,
“Yes, I saw that happen. The
older person did that,”
when they were questioning
So there are dangers of repeated questioning
and implanting ideas in children
and those dangers are real.
So we have to conduct a
forensic interview carefully.
We do not lead the child, in that
we say, “Hey, did he do this?”
We allow the child
to tell the story.
It’s important to detail responses
from the child early in the interview.
We have to see what they say
and document it thoroughly.
Ask open-ended questions.
Questions where the child
can’t answer yes or no
but has to expound on the circumstance
and allow for silence and hesitation.
It’s okay to pause, let the
child consider their answer.
That allows for the child to then express
themselves and give new information.
And certainly, we need to record
these interviews for legal purposes.
When we’re examining children, there are
certain key findings of child abuse
that you should know about.
This is the classic shaken baby syndrome
and an ophthalmologic evaluation
may reveal retinal hemorrhages.
So you can see here on
this baby who was shaken
that retinal hemorrhages
have occurred in the retina.
Now, it takes some experience
looking at retinas
and so often, we’ll call a
to document and photograph the eyes.
If we suspect child abuse, it’s
important to get a skeletal survey.
A skeletal survey is an X-ray of
literally every bone in a child
and we look at all those and
look for findings of fractures.
Here’s a classic child abuse
fracture of posterior rib fractures.
We can see those bulges.
That’s an older posterior rib fracture.
Posterior rib fractures are
classic for child abuse
and they’re from squeezing an infant.
They’re not from falling on the ribs.
So the story is really squeezing, as in a
parent frustratingy squeezing their child.
You may repeat in certain causes
skeletal surveys two weeks later
if there’s an acute event because sometimes
fractures show up a little bit delayed.
You also will see things
like midshaft fractures.
These are very unlikely to be
from a non-abusive circumstance.
This is sort of a classic
finding you can see on the hips
where this patients has suffered
both a femoral head fracture
as well as a pelvic fracture and you
can see those evidence of fractures.
And this type of fracture
right here is pathognomonic
for a child abuse situation
from a torsed leg injury.
And then the last is we will
often CT the brain if we expect
some sort of shaken
baby or head trauma.
And here’s an example of
a child who was abused
and you can see the hemorrhage, which
is much lighter on the CT scan
and CT is the best way to check
to acute blood for imaging.
And here on a closeup,
you can see the blood layering
out in the subarachnoid space.
So if a child has been
abused, what do we do?
Well the first is, of course,
supportive care for the injuries.
If there’s a broken bone, we will
put the child in a cast as needed.
Rib fractures generally
don’t require casting.
Remember that doctors are legally mandated
reporters to child protective services.
If you suspect child abuse, the law states
that you have to report that child.
Keep in mind it’s not your job
to decide whether it happened.
That is the responsibility of
child protective services.
You simply report when
you suspect child abuse.
It’s up to them to figure out
whether it was abuse or not.
It’s important to document with
photos and video as much as possible.
That information is admissible
in the court of law
and sometimes we’ll document
things in written way
that might leave things somewhat
questionable by the defence.
So a photograph and a video is critical for
documentation of these children’s injuries.
And lastly it’s critically important
to consult a child abuse pediatrician,
this is a subspecialty in pediatrics,
whenever you can get
your hands on one.
Child abuse pediatricians are
incredibly helpful for us
in terms of not only providing
necessary legal counsel
and for help with
placement of the child,
but also for representing the child’s
interest in the court of law.
So during trials, child abuse
pediatricians are routinely called upon
to testify about the degree of injury
whether or not it could be
consistent with accident or abuse.