Signs and Symptoms of Possible Child Abuse

Introduction
Physical Abuse
Bruising
Fractures
Femoral (thigh bone) Fractures
Skull Fractures
Metaphyseal Fractures
Other Fractures
Implication for Practice
Burns
Child Sexual Abuse
Signs of physical abuse
The Child Sexual Abuse Jigsaw
Physical signs of Child Sexual Abuse
Physical signs of Child Sexual Abuse – Girls
Physical signs of Child Sexual Abuse – Boys
Emotional Abuse
Neglect
The Jigsaw of Neglect

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, bleeding or a discharge. The child may be irritable or vomiting.

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 indeed that medical/nursing staff hear the accounts given by other agencies.

Physical Abuse

Physical abuse describes physical injuries to a child as a result of acts of commission or omission. This includes anything from a hand slap to death by suffocation. Injuries may be caused by blows, punches, kicks, shakes, bites, belts, scalds, burns, suffocation, drowning or poisoning.

The injuries may be:

• Soft tissue is, bruising, laceration, burns and scalds.
• Bony i.e., fracture
• Intra-cerebral (brain) injury
• Intra-abdominal and mouth injuries
• Intra-orbital.

Note – illness fabricated or induced by carers is usually classified with physical abuse.

Bruising

What do we know about bruising?

Bruising is strongly related to mobility.

Once children are mobile they sustain bruises from everyday activities and accidents.

Bruising in a baby who is not yet crawling, and therefore has no independent mobility, is very unusual.

Only one in five infants who is starting to walk by holding on to the furniture has bruises.

Most children who are able to walk independently have bruises.

Bruises usually happen when children fall over or bump into objects in their way.

Children have more bruises during the summer months.

Where would you expect to see bruising from an accidental injury?

The shins and the knees are the most likely places where children who are walking, or starting to walk, get bruised.

Most accidental bruises are seen over bony parts of the body, for example, knees and elbows, and are often seen on the front of the body.

Infants who are pulling to stand may bump and bruise their heads, usually the forehead.

Fractures are not always accompanied by bruises.

When should you be concerned?

There are some patterns of bruising that may mean physical abuse has taken place.

Abusive bruises often occur on soft parts of the body, for example cheeks, abdomen, back and buttocks.

The head is by far the commonest site of bruising in child abuse.

Clusters of bruises are a common feature in abused children. These are often on the upper arm, outside of the thigh, or on the body.

As a result of defending themselves, abused children may have bruising on the forearm, face, ears, abdomen, hip, upper arm, back of the leg, hands or feet.

Abusive bruises can often carry the imprint of the implement used or the hand.

Non-accidental head injury or fractures can occur without bruising.

Can you age a bruise accurately?

The answer is no.

Estimates of the age of a bruise are currently based on an assessment of the colour of the bruise with the naked eye. The accuracy of observers who estimate the age of a bruise visually is no better than 50 per cent. The evidence is that we cannot accurately age a bruise from an assessment of colour, from either a clinical assessment or a photograph. A practitioner who offers a definitive estimate of the age of a bruise in a child by assessment with the naked eye is doing so from their own experience without adequate published evidence.

Implications for practice

A bruise should never be interpreted in isolation and must always be assessed in the context of the child’s medical and social history, developmental stage and explanation given. Any child who has unexplained signs of pain or illness should be seen promptly by a doctor. Unless you are a doctor do not try to make a diagnosis, just describe what you see, mistakes can occur when birthmarks are mistaken for bruises.

Bruising that suggests the possibility of physical child abuse includes:

• Bruising in children who are not independently mobile
• Bruising in babies
• Bruises that are seen away from bony prominences
• Bruises to the face, back, abdomen, arms, buttocks, ears and hands
• Multiple bruises in clusters
• Multiple bruises of uniform shape
• Bruises that carry an imprint of an implement or cord.

This information is based on a systematic review of all the quality work in the world literature about bruising on children. Bruising is the most common injury to a child who has been physically abused. These key messages should help you to know when to be concerned about bruising on children.

Fractures

A fracture in a child or young person should always be assessed in light of the full history, physical findings, x-ray appearances, special investigations and the developmental stage of the child.

What fractures are indicative of abuse?

85% of accidental fractures occurred over 5 years of age.

80% of abusive fractures occurred under 18 months of age.

25% of all fractures under one year were due to abuse.

Highest incidence of abusive fractures was in children under 4 months old.

Abusive fractures are more common in children less than one year of age than those older than 2 years.

Abused children are more likely to have multiple fractures than non-abused children.

Femoral (thigh bone) Fractures

Abusive femoral fractures occur predominantly in infants.

Significantly more abusive femoral fracture arise in children who are not yet walking.

Skull Fractures

Abusive and non-abusive skull fractures are commoner in young infants.

Overall probability that a skull fracture is due to abuse is 23% rising to 37% if complex.

Linear fractures are the commonest abuse and non-abusive skull fractures.

Multiple or bilateral fractures or those that cross suture lines were more common in abused children.

Metaphyseal Fractures

These are small chip or crack fractures that occur at the ends or growing points of long bones. They are usually due to twisting or gripping injuries.

Metaphyseal fractures are more commonly described in physical child abuse than in non-abuse.

Classical metaphyseal lesions will only be found if rigorous radiological techniques are applied.

Metaphyseal fractures are one of the commonest fractures in fatal child abuse.

Remember that birth trauma can cause metaphyseal fractures in breech deliveries. There are also reports of metaphyseal fractures in inappropriately administered physiotherapy particularly to pre-term infants.

Other Fractures

Vertebral, pelvic, hands, feet and sternal fractures (breast bone) occur in physical abuse, appropriate radiology is required for detection.

It is important not to mis-diagnose some common fractures, for example an undisplaced spiral fracture of the tibia (lower leg bone) without an associated fracture of the fibula is most likely to be due to a “toddler fracture” particularly if the child is a boy less than 2½ years.

Implication for Practice

Fractures in children less than 18 months of age should be assessed for possible child abuse.

Multiple fractures are more suspicious of abuse.

X-Rays

Burns

The following features may suggest abuse:

Uncommon sites and appearances of burns inconsistent with the explanation or with the development/ability of the child

Round red burns on soft, tender, non protruding parts of the body such as inside of mouth, inside of legs, behind knees, inside of arms or on genitals

Child Sexual Abuse

Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (eg. rape or buggery) or non-penetrative acts. They may include involving children in looking at, or in the production of, pornographic material, or encouraging children to behave in sexually inappropriate ways.

Contact may involve:

• Touching, oral contact of breasts, genitalia or anus, masturbation.
• Inserting digits or objects into vulva and anus.
• Rape with attempted/achieved penetration of vagina or anus.
• Oral penetration.

Non-contact:

• Exhibitionism.
• Pornography.
• Erotic talk.

Physical injury may be part of the sexual assault, eg bites on the breasts or sadistic burns on areas as seen in non-sexual assault.

Children of all ages are abused, including infants under a year old, and it is quite common to find that all the children in the family have been abused.

Sexual abuse is damaging to the child, with effects which can be long-lasting on behaviour, emotional state and social relationships. The abuser threatens and demands secrecy. The children feel helpless and may even feel responsible for the badness.

The families with abused children are described as less cohesive, more disorganised and more dysfunctional than those of non-abused children.

The abuse comes to light if the children disclose either on their own or if other suspect because of something seen or behavioural clues.

Older children understand that disclosure may destroy the family, so continued silence and guilt can seem a logical outcome. After disclosure, there is sometimes such pressure from the family that the child retracts, but usually disclosure begins the long process of treatment of the child, the family; and perhaps also the abuser, who may move gradually from denial to acceptance of responsibility.

The examination of the sexually abused child includes:

• Sympathetic approach, gender choice of examiner, the child’s right to refuse
• Therapeutic aspect of the examination, especially if no abnormalities found, part of the healing process
• May need to carry out examination in a forensically secure environment
• Need to construct a differential diagnosis to explain findings with evidence for each possible diagnosis
• A full paediatric assessment including stage of puberty

Signs of physical abuse

• The ano-genital area
• Signs of sexual assault detected as part of a forensic examination
• Infection, arrange appropriate investigations
• Contraceptive needs
• Follow-up to see healing and to arrange psychological treatment for possible stress related symptoms

The Child Sexual Abuse Jigsaw

Physical signs of Child Sexual Abuse

• Disclosure
• Symptoms eg, sore bottom
• Signs eg vaginal bleeding or discharge
• Behaviours eg sexualised
• Psychological symptoms eg anger, depression.
• Expert medical opinion vital as some suspicious signs may be caused by poor hygiene or by skin diseases

Physical signs of Child Sexual Abuse – Girls:

• There are no signs of recent assault in about 50% of referrals
• Reddening which is non-specific
• Vulvo-vaginitis – check for STD
• Acute signs are tears in hymen, vagina, oedema, erythema, bleeding
• Attenuation of hymen (thinning)
• Hymenal opening gaping and wide
• Healed tears may heal as notch, significance greatest if posterior
• STD
• Foreign body. (Rare – usually indicates CSA)
• Scars are rare
• Signs of physical assault – see associated non-sexual injuries
• Thick, long posterior labial fusion
• Pregnancy

Physical signs of Child Sexual Abuse – Boys:

• Bruising of penis or scrotum
• Torn frenulum of penis
• Ligature, burn, bite, cut to penis
• Urethral injury
• Foreign body (see above)
• STD.

Anal Signs

Acute signs include erythema, anal fissure, gaping anus, haematoma (of anal margin), selling of anal margin, muscosa prolapsing/lax anus.

More chronic signs include un-healed fissure, lax sphincter, reflex anal dilatation.

Non-specific signs such as dilated veins peri-anally, skin tag associated with healed fissure, congenital tag.

Scars are highly significant and a history is needed ? previous trauma.

Funnelled anus (deeply set anus, usually in adolescence)

Foreign body (see above)

STD – care must be taken and appropriate swabs – a local protocol with the Genito-Urinary Department is needed.

Older children may have no signs of anal penetration, especially is a lubricant is used.

Associated Non-Sexual Injuries

One in six sexually abused children has also been physical abused. Any injury may be seen, but patterns particularly associated are:

• Grip mark on limbs
• Signs of partial strangulation, linear marks round neck
• Bruises over lower abdomen
• Love bites
• Injuries to penis, perineum, anus, labia.

Differential Diagnosis

Accident eg straddle injury, cross-bar

Early onset of puberty (girls) presenting with bleeding

Congenital abnormality eg septate hymen

Infection eg streptococcal

Infestation eg thread worms

Skin disorder eg Lichen sclerosis, eczema

Inflammatory bowel disease, eg Crohns disease

Rectal polyp presenting with bleeding

Severe constipation leading to an acute anal fissure.

Emotional Abuse

Emotional abuse is part of all the other abuses but also occurs without them. Thus, a child witnessing family violence may be physically well cared for but emotionally distraught. Emotional abuse includes discouragement, ridicule, unfairness, hostility, threats and bullying: ‘You are bad, stupid, useless and I don’t love you’.

Emotional abuse is endemic in society and may be used by adults as a form of control in institutions, e.g. in schools, hospitals.

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
• Continual self-deprecation
• 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
• Only happy at school or kept away
• Pseudo mature or explicit sexual behaviour
• Open masturbation or aggressive sex play with peers
• Stomach pains without medical explanation
• Self-harm, mutilation, overdose or attempted suicide

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, emotionally.

Failure to thrive occurs when a child fails to grow at the expected rate due to an inadequate intake of calories. 5% of children under 5 years FTT and the majority of children who FTT have no organic disorder (coeliac disease, cyanotic heart disease etc). This is evident on examination. Investigations are unnecessary apart from a check for anaemia.

FTT may be associated with neglect and emotional deprivation when these are present but many cases are simply due to lack of calories in feeds, for a variety of reasons. Developmentally, the child may be delayed, language and social skills including attention are most affected. The child is found to lack a strong attachment figure.

Management of FTT depends on the severity of the child’s condition but the majority are seen by the primary care team (GP, health visitor, community dietician) while only a few need to be referred to the specialist team.

Neglect

‘The child has a right to expect, and the adult caretaker has a duty to provide: food, clothing, shelter, safekeeping, nurture and teaching’. Failure to provide these constitutes neglect (Cantwell & Rosenberg 1990). This includes physical and developmental growth as well as educational, medical and social neglect.

Emotional abuse and neglect are pervasive and much goes unrecognised. ‘Working Together’ (2000) defines neglect as ‘the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development’ (the concept of ‘significant harm’).

The needs of a child include:

• Adequate food
• Medical and dental care
• Love and attention
• Learning opportunities
• Shelter and clothing
• Education
• Protection from harm
• House and safe play areas.

Most damaging to the child is the failure to meet psychological needs or ‘a home low in warmth and high in criticism’, which may affect children from any strata of society. (Message from Research 1995)

There is a strong link between neglect and:

• Poverty
• Disability
• Parental alcohol or substance misuse
• Homelessness, unemployment.

In addition, the neglected child

• May fail to grow and develop to his full potential
• Is at risk of long-term disability following accidents, respiratory disease
• Is at risk of poor mental health
• Is more likely to have inter-current infection especially chest infections, ear infections
• May have incomplete immunisation.

Signs of possible neglect include:

• Dirty, inappropriate clothing, often too large, wellies
• Dirty body, smells, nails thick, yellow, dirty
• Hair thin, wispy
• Height, weight, mid-upper arm or head circumference demonstrate poor growth.

Development is delayed particularly in language and social skills may be below average:

• Play is immature and may lack imagination
• Expressive language delayed
• At school, delayed language affects reading
• Hearing may be impaired due to neglect of “glue ear”
• May have neglected squints and visual impairments

Behaviour as observed and reported: distractible, short attention span, over friendly, aggressive, withdrawn etc.

In cases of neglect, it is important to compile a diagnostic jigsaw. In reviewing a child, the various parts of the picture, the history, signs, medical investigations and social background are fitted together like a jigsaw, leading to a diagnosis, but this may take time, for example, in assessing growth.

The Jigsaw of Neglect

The effects on children of neglect and social deprivation after Skuse (1993):

Produced by members of a South West Local Safeguarding Children’s Board