PHYSICAL CHILD ABUSE
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What is Physical Abuse?
Physical abuse is any non-accidental act that results in physical injury. Inflicted physical injury most often represents unreasonably severe corporal punishment or unjustifiable punishment. This usually happens when a person is frustrated or angry and strikes, shakes, or throws the child. Intentional, deliberate assault, such as burning, biting, cutting, poking, twisting limbs, or otherwise torturing a child, is also included in this category of child abuse.
Indicators of Physical Abuse
These indicators are used to help distinguish accidental injuries from cases of suspected physical abuse:
LOCATION & TYPES OF INJURY
Padded areas as the buttocks, back of legs, genitalia and cheeks are more concerning in that it takes more force to cause bruising. Bruises happen when the blood vessels break under the skin. Thus children who are old enough to walk often fall and have bruises over boney surfaces such as the forehead, knees, shins where blood vessels are breaking between two hard surfaces (the floor for example and the underlying bone). However, simple falls and even disciplinary spanking with an open palm should not be forceful enough to cause bruising to the buttocks. Protected areas such as ears, neck, and upper lip are more concerning because it is difficult to accidentally bump or fall on these areas. Patterned injuries such as loop marks, slap marks, or grab marks are highly suspicious and in some cases indicative of inflicted trauma.
The history includes all facts about the child and the injury, including:
• Statements by the child that the injury was caused by abuse.
• Knowledge that a child’s injury is unusual for a specific age group (any fracture in an infant).
• Unexplained injuries (parent, caretaker, or child is unable to explain reason for injury; there are discrepancies in explanation; blame is placed on a third party; explanations are inconsistent with medical diagnosis).
• Parent or caretaker delays seeking care for a child or fails to seek appropriate care.
Children may exhibit new or concerning behaviors for a number of reasons, including child abuse as well as other sources of childhood stress such as parental divorce, death in the family, etc. If a child exhibits drastic behavioral changes, is excessively aggressive, violent or destructive, is cruel to animals, or becomes visibly depressed or suicidal, a serious mental health evaluation should be done.
In addition, these behaviors may be an indication that the child has been abused. If abuse is suspected, the mandated reporter must inform Child Protective Services or law enforcement about their concerns.
Damage to Skin & Tissue
Bruises, also referred to as contusions, resulting from abuse are found on multiple surfaces of the body, particularly the buttocks, back, genitals, and face. They may appear in a characteristic pattern (outline of hand, paired bruises from pinching), or they may clearly resemble an impression of an item of jewelry (a ring), or a disciplinary imprint (a paddle, switch, or coat hanger). Linear bruise marks, strap marks, or loop marks going around a curved body surface are almost always evidence of abuse.
It is not possible to date bruises. The colors red, blue, purple or black can occur at any time. In addition, bruises of identical age and cause on the same person may look different and may resolve differently.
In cases where bruises are suspected bite marks, investigators should also be prepared to seek the expertise of forensic odontologists.
As with bruising, the multiplicity and location of the wounds should be considered. For example, lacerations under the tongue or those of a torn frenulum (the small piece of tissue connecting the gum to the lip) could be caused by falling with an object in the mouth or by the use of excessive force during feeding. Both are suspicious injuries when the victim is an infant who is still unable to stand.
Whipping a child with a belt buckle or belts or cords that are looped may cause lacerations resembling a “C” or “U” shape or other wounds with distinctive shapes.
Bite marks may be found on any part of a child’s body. They may appear to be doughnut shaped, double horseshoe shaped, or oval in configuration. Individual teeth or a blurry area with varying colorations may be observed, depending on the age of the bite mark lesion. Time is of the essence in recording bite marks through photography and/or videotaping because some lesions will become less distinct with time.
Photography, employing non-distorting cameras, with rulers or scales adjacent to the lesion, should be accomplished by forensic dentists, skilled evidence technicians, or other experienced individuals. Salivary swabbing should be collected, because they may be used to determine the blood type or even DNA of the biter. In penetrating bite marks, services of the individuals listed above should also be obtained in order to secure accurate impressions of the bitten area.
If properly collected and analyzed by experienced forensic dentists, bite mark evidence can point to the guilt or innocence of a perpetrator suspected of involvement in the physical or sexual abuse of a child.
The location of a burn and its characteristics (shape, depth, margins, etc.) may indicate abuse. It is important to keep in mind that children instinctively withdraw from pain. Burns, without some evidence of withdrawal, are highly suspect because a child will usually try to escape, which will result in splashes, uneven burns and sometimes burns on the hands.
Scalding a child with hot liquid is the most common abuse burn. Young infants are commonly scalded by immersion, and older children by having liquids thrown or poured on them.
When children are forcibly held in hot water, there are often sharply demarcated burns. If held in water in a “jackknife” position, only the buttocks and genitalia may be burned. If held down forcibly in a sitting position, the center part of the buttocks (if pressed tightly against the tub) is spared from burning, thus resulting in a “doughnut shaped” burn. If the extremities are forcibly immersed in hot water, “glove” or “sock” burns to the hands or feet may result. The burns are often symmetric and an immersion line is readily evident Abuse may also be suspected when burns are pointed or deeper in the middle. This indicates that hot liquid was poured on, or a hot object (poker, utensil) pressed into the skin.
Another type of burn characteristic of abuse has the shape of a recognizable object evenly burned into the victim’s skin. These burns indicate forced contact or “branding” with, for example, the grill of an electric heater, the element of an electric stove, or an iron.
Cigarette burns are difficult to diagnose, but when inflicted they are often multiple and are usually found on the palms or soles. There is a searing effect, perhaps with charring around the wound.
Rope “burns” appear around wrists or ankles when children are tied to beds or other structures.
Damage to Internal Organs
Blunt blows to the body can cause serious internal injuries to the liver, spleen, pancreas, kidneys, and other vital organs and occasionally can cause shock and result in death. Internal injuries are the second leading cause of death for victims of child abuse.
Detectable surface evidence of such trauma is present only about half the time. Physical indicators of serious internal injuries may include distension of the abdomen, blood in the urine, vomiting, and abdominal pain.
Damage to the Brain
Head injuries are the most common cause of child abuse related deaths and an important cause of chronic neurological disabilities.
Whenever abuse or neglect is suspected, a careful examination of the child’s eyes and nervous system should be performed to look for signs of intracranial injury. For certain groups of suspected victims, a full skeletal trauma series may be necessary as well as toxicology. Serious intracranial injury can occur without visible evidence of trauma on the face or scalp. Children with any soft tissue injury to the head should be neurologically assessed and have an ophthalmological evaluation to look for retinal hemorrhages. These injuries may cause brain damage or death if undetected and untreated.
When a child is in an unconscious or unresponsive state and there is no external evidence of injury and no adequate explanation for the child’s state, head injury from possible abuse should be considered. The caretaker’s explanation for a fall should be carefully documented including who was present, the distance of the fall, the type of surface hit, and time of the injury.
The medical evaluation is critical but should not stand-alone. A complete evaluation, even with severe injury, includes a psychosocial evaluation of the family, caretakers and home, which can be completed by hospital social workers. In general, these evaluations should be considered in all cases where child abuse is suspected.
ABUSIVE HEAD TRAUMA
Abusive head trauma, (Shaken Baby Syndrome), describes a constellation of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant. The degree of brain damage depends on the amount and duration of the shaking and the forces involved in the impact to the head. Signs and symptoms range on a spectrum of neurological alterations from minor (irritability, lethargy, tremors, vomiting) to major (seizures, coma, stupor, death). These neurological changes are due to destruction of the brain cells secondary to trauma, lack of oxygen to the brain cells, and swelling of the brain.
Extensive retinal hemorrhages in one or both eyes are found in the vast majority of these cases. The classic triad of subdural hematoma, brain swelling, and retinal hemorrhages are accompanied in some, but not all cases, by bruising of the part of the body used as a “handle” for shaking. Fractures of the long bones and/or of the ribs may also be seen in some cases. Rib fractures or metaphyseal fractures (also called bucket handle or corner fractures) are particularly concerning in young children and if seen should prompt further investigation for a possible shaking event. In many cases, however, there is no external evidence of trauma either to the head or the body.
Approximately 20 percent of cases are fatal in the first few days after injury. Survivors suffer from handicaps ranging from mild learning disorders and/or behavioral changes, to moderate and severe, such as profound mental and developmental retardation, paralyses, blindness, inability to hear, or a permanent vegetative state.
A careful post mortem examination is required of all infant deaths in California. These examinations should always include evaluation for signs of intracranial bleeding, retinal hemorrhages, and points of impact on or within the body. Evaluations of potentially suspicious cases also should include forensic lab study by protocol, including toxicology, microscopic tissue examination (including the retina), and a full trauma x-ray series.
Damage to the Skeleton
Any unexplained fracture in an infant or toddler is cause for additional inquiry or investigation. Rib fractures, especially of back ribs, are the most common fractures found in abused children and are caused from either blunt force (hit) or compression (squeezed).
Fractures are most suspicious for inflicted trauma when there are multiple lesions, they are in different stages of healing, and there are unsuspected lesions. Other fractures that raise suspicion are: metapyhseal fractures (also known as corner, chip, or bucket handle fractures) which are at the end of long bones and may be fractures from excess traction, jerking, and twisting injuries; multiple rib fractures, especially back rib fractures; and healing or healed fractures without an explanation revealed by x-rays. For young victims, x-ray bone surveys are important tools used to diagnose suspected physical abuse.
Radioisotope bone scans may pick up healing fractures, subperiosteal hematomas, etc. A pediatric radiologist should be consulted on all suspicious cases.