Introduction
A symptom is something you complain of if you are unwell or injured. For example, a child who has been abused may complain of pain, soreness or bleeding.
A sign is an altered state of the body that you can actually see when the child or young person is examined, for example a bruise, an altered shape of a limb because of a fracture, or redness and blistering due to a burn.
Symptoms and signs in child abuse have to be taken in the context of the medical and social history (the story) and the developmental status of the child. For example, how does one explain a fractured femur in a child who is not yet walking?
Possible indicators of possible abuse in a child or young person include:
- Late reporting
- Inconsistency between the story given and the injuries that you see
- A story which changes according to who tells it
- Frequent attendances in Emergency Departments
- Bruising or fracture in a child under the age of one year.
It may be important to include child abuse as part of the differential diagnosis (list of possible diagnoses) for a number of presentations in children, including bruising, fractures, irritability, vomiting etc. The reasons for including possible child abuse in the differential diagnosis should always be documented carefully with the evidence. Likewise, any reasons for considering that symptoms or signs are not due to abuse should also be carefully reported if necessary.
It is worth emphasising that the story given must be drawn from as many sources as possible and if an allegation of child abuse is being investigated jointly by Police and Social Services, it is very important that medical/nursing staff hear the accounts given by other agencies.
Emotional Abuse
Emotional abuse is one of the most damaging forms of abuse and almost always accompanies other forms of abuse. It includes persistent criticism, denigration, rejection and scapegoating.
Behaviours/symptoms suggestive of emotional abuse
- Continuous withholding of approval and affection by parent/carer
- Discipline severe and inappropriate, or non-existent, with few or no boundaries set
- Exploitation by parents/carer to fulfil their needs
- Fear of new situations
- Impaired ability for play and enjoyment
- Lack of curiosity and natural exploration, air of detachment
- Inappropriate emotional responses to painful situations
- Delayed social and language skills
- Persistent head banging or rocking in a younger child
- Enuresis and encopresis (wetting and soiling)
- Compulsive stealing/scrounging
- Drug/solvent misuse
- Low self-esteem, feeling of worthlessness
- Social isolation (including from friends)
- Behavioural difficulties including aggression, disruptive behaviour
- Attention seeking
- Eating disturbances, poor growth
- Family history of domestic violence, mental illness of a carer or substance misuse
- Depression, withdrawal
- Frozen watchfulness
- Stomach pains without medical explanation
- Self-harm, mutilation, overdose or attempted suicide
Non-organic Failure to Thrive or Faltering Growth
Medical and Nursing professionals may define Failure to Thrive (FTT) as a faltering growth pattern. Other agencies, e.g. Social services may use the term to embrace thriving in the wider sense, physically, developmentally and emotionally.
Failure to thrive occurs when a child fails to grow at the expected rate. 5% of children less than 5 years fail to thrive and many of those children have no organic disorder (coeliac disease, cyanotic heart disease etc).
Non-organic FTT may be associated with neglect and emotional deprivation but many cases are simply due to lack of calories for a variety of reasons.
Developmentally, the child may be delayed; language and social skills including attention are most affected. In its chronic form, non-organic failure to thrive can result in greater potential to more serious illnesses, reduction in potential stature and with young children particularly, the results may be life threatening over a relatively short period.
