Child abuse
Dr. Ravi Nanayakkara
Definition
• Acts of commission or omissions
leading to actual or potential damage
to health and development and
exposure to unnecessary suffering.
Intermediate objectives
• Describe the different types of child
abuse
• Discuss the detailed medico legal
investigation of a case of suspected
child abuse and further management.
• Discuss how you would express your
opinion in relation to medico legal
aspects of the case and fill MLEF and
MLR.
Contents
• Definitions of different types of child
abuse, predisposing factors, history,
physical
examination
and
investigations done in suspected case.
• Characteristic injury pattern in child
physical abuse.
• Management of victims, rehabilitation
and case conference.
Types of abuse
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Physical child abuse
Sexual child abuse
Child labour/child soldier
Neglect
Psychological and emotional abuse
Munchousen’ syndrome by proxy
Intentional poisoning
Physical child abuse
• Abusers
Parent
Guardian
Consorts of either spouse
Baby sitters
Teachers
Relation …..
Physical abuse is characterized by the
infliction of physical injury as a result of
punching, beating, kicking, biting,
burning, shaking or otherwise harming a
child. The parent or caretaker may not
have intended to hurt the child; rather,
the injury may have resulted from overdiscipline or physical punishment.
History
• Vague and conflicting history
• Different histories given by
parent/guardian at different times
• Accidental fall
• Injury during play
• Assaulted by elder brother
• Punishment by teacher
• Some times children may be too young
to express themselves
Examination
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Scared
Avoid eye contact
Sad
Depressed
Apathy
Injuries
• Usually inflicted by manually
hitting with hands, shaking, throwing
• Weapons if used common household
weapons
canes, slicks
• Burns
Hot water, heated objects
• Cutting and stabbing rare
Injuries
Head and face
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Lip injuries
Torn frenulum
Nail marks
Slap marks
Bite marks
Areas of alopecia following pulling of hair
Scalp contusions
Eye injuries
• Black eyes
• Subconjuctival haemorrhage
• Bilateral vitreous haemorrhage
• Retinal, subretinal, preretinal
haemorrhage
• Retinal detachments
• Anterior chamber haemorrhage
• Dislocated lens
Ear injuries
• Ruptured ear drum
• Chronic suppurative otitis media
• Cauliflower ear due to forceful slapping
• Tin ear syndrome
unilateral ear bruising,
ipsilateral cerebral oedema,
haemorrhage retinopathy
Injuries
• Tram line contusions
• Grip marks
• Pinch marks
• Patterned injuries from belts, buckles
• Tying of penis to prevent frequent bed
wetting
• Burn injuries with scalds
• Burn injuries with flame and heated objects
• Injuries of different stages of healing
fresh, healing, healed with scar
• Injury pattern and age of injuries
inconsistent with the history
Bruises
• Most common indication of physical abuse
• Occurs in >50% of abused children
• Bruises are uncommon in infants
< 6 months.
– “Those who don’t cruise rarely bruise.”
• Two characteristics separate abusive from
accidental bruises:
LOCATION
PATTERN
Location
ACCIDENTAL
ABUSIVE
Shins
Anterior thigh
Lower arms
Upper arms
Under chin
Neck
Forehead
Face
Hips
Buttocks
Elbows
Trunk
Ankles
Ears
Bony prominences Genitalia
Bruises in Physical Child Abuse
Fingertip bruises consisting of circular or oval
bruises from squeezing, gripping, or grabbing
injuries.
Linear petechial bruises in the shape of a
hand caused by capillaries rupturing at the
edge of the injury from the high-velocity
impact of the hand slap.
Pinch marks consisting of paired, crescentshaped bruises separated by a white line.
Bruises in Physical Child Abuse
High-velocity impact causing a rim of petechiae
outlining the pattern of the inflicting instrument, e.g.,
parallel sided marks from sticks—“tramline bruising”
Higher velocity impacts causing bruising underlying
the injury in the shape of the object used, (e.g.,
wedge-shaped bruises from kicks with shoes).
Pressure necrosis of the skin from ligatures, causing
well-demarcated bands partially or fully encircling
limbs or the neck.
Coarse speckled bruising from impact injuries
through clothing.
Location
Commonly associated with physical child abuse
• Facial—soft tissues of the cheek, eye, mouth, ear, mastoid, lower jaw,
frenulum, and neck.
• Chest wall.
• Abdomen.
• Inner thighs and genitalia (strongly associated with sexual abuse).
• Buttock and outer thighs (commonly associated with punishment
injuries).
• Multiple sites.
Commonly associated with accidental injury:
• Bony prominences.
• On the front of the body. Numbers:
• The number of accidental bruises increases with increased mobility of
a child.
• More than 10 bruises in an actively mobile child should raise concern.
Differential Diagnosis of Bruising
• Accidental injury—commonly on bony surfaces,
appropriate history.
• Artifact—dirt, paint, felt tip, or dye from clothing or
footwear.
• Benign tumors—halo nevus, blue nevus, or hemangiomas.
• Vascular and bleeding disorders—thrombocytopenic
purpura, Henoch–Schoenlein purpura, hemophilia,
or purpura in association with infection
(e.g.,meningococcal septicemia, seconday syphilis).
• Disturbances of pigmentation—café-au-lait patches or
Mongolian blue spots.
• Erythematous lesions—erythema nodosum.
• Hereditary collagen disorders—osteogenesis imperfecta
or Ehlers–Danlos syndrome.
• Allergic reaction
Bite Marks
A bite mark is a mark made by teeth alone
or in combination with other mouth parts
and may be considered a mirror image of
the arrangement and characteristics of the
dentition. Human bite marks rarely occur
accidentally.
Children can be bitten in the context of
punishment, as part of a physical assault, or
in association with sexual abuse. Children
can also be bitten by other children.
Thermal injuries
• Scalds—immersion, pouring or throwing
a hot liquid onto a child. The affected
skin is soggy, blanched, and blistered. The
shape of the injury is contoured. The
depth of the burn is variable.
• Contact burns—direct contact of a hot
object with the child. Characteristically,
the burn is shaped like the hot object,
with sharply defined edges and usually of
uniform depth. The burn may blister.
•Fire burns—flames from fires, matches, or lighters in
close or direct contact with the skin, causing
charring and skin loss with singeing of hairs.
• Cigarette burns—inflicted direct contact leaves a
characteristically well-demarcated circular or oval
mark with rolled edges and a cratered center,
which may blister and tends to scar. Accidental
contact with a cigarette tends to leave a more
superficial, irregular area of erythema with a tail.
• Chemical burns—the chemical in liquid form is
drunk, poured, or splashed onto the skin, or in solid
form is rubbed on the skin. The skin may stain, may
have the appearance of a scald, and may scar.
Differential Diagnosis of Burns
 Cellulitis, erysipelas
 Sunburn
 Contact dermatitis
 Diaper rash
 Drug reaction
 Psoriasis
 Infection—staphylococcal or streptococcal
(impetigo or scalded skin syndrome).
 Allergy—urticaria or contact dermatitis.
 Insect bites.
 Bullous diseases—porphyria or erythema multiform
Features of Thermal Injuries Suggestive of
Child abuse
• Repeated burns.
• Sites—backs of hands, buttocks, feet, and
legs.
• Types—clearly demarcated burns
shaped like a particular object, immersion
burns with a tide mark (clear edge) and no
splash marks.
• The presence of other NAIs.
Fractures
Any fracture can occur as a result of NAI, but some have a high
specificity for abuse
• Metaphyseal—a shaking, pulling, or twisting force
applied at or about a joint, resulting in a fracture
through the growing part of the bone.
• Epiphyseal separation—resulting from torsion of a
limb, particularly in children younger than 2 years
old.
• Rib—resulting from severe squeezing or direct
trauma; posterior rib fractures virtually
pathognomonic of NAI and commonly associated
with shaking injury.
• Scapular—resulting from direct impact.
• Lateral clavicle—resulting from excessive traction
or shaking of an arm.
• Humerus or femur
transverse fractures from angulation, including a
direct blow
spiral fractures from axial twists with or without axial
loading
oblique fractures from angulation, axial twisting with
axial loading.
• Vertebral fractures—resulting from hyperflexion injuries,
impact injuries, or direct trauma.
• Digital fractures—resulting from forced hyperextension
or direct blows.
• Skull fractures—resulting from blunt-impact injuries,
particularly occipital fractures and fractures that are
depressed, wide (or growing), bilateral, complex,
crossing suture lines multiply, or associated with
intracranial injury .
• Periosteal injury—resulting from pulling or twisting of a
limb separating the periosteum from the surface of the
bone, leading to hemorrhage between the periosteum
and the bone and subsequent calcification.
Other features of skeletal injury suggestive of abuse
include the following:
• Absence of an appropriate history.
• Multiple fractures.
• Fractures of differing ages.
• Fracture in association with other features of NAI
(e.g., bruising at other sites).
• Unsuspected fractures (recent or old) found when
X-rays taken for other reasons
Dating Fractures
• Resolution of soft tissues — 2 to 10
days.
• Early periosteal new bone — 4 to 21
days.
• Loss of fracture line definition — 10 to
21 days.
• Soft callus — 10 to 21 days.
• Hard callus — 14 to 90 days.
• Remodeling — 3 months to 2 years.
Differential Diagnosis of Fractures
• Minor falls
– Do not cause fractures in most instances
– Studies show very low incidence of fractures
from short falls
• Obstetrical/birth trauma
– usually produces only humeral and clavicular
fractures
– no rib fractures
• Prematurity
– Osteopenia can lead to fractures
DDX: Skeletal Fractures
• Congenital:
– Osteogenesis imperfecta
– Menke’s syndrome
• Nutritional / Metabolic:
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Copper deficiency
Rickets
Scurvy
Renal osteodystrophy
• Infectious:
– Congenital syphilis
– Osteomyelitis
• Neoplasm:
– Leukemia
– Bony metastases
• Normal variant:
physiological periosteal reaction
(symmetric and smooth around
the long bones of children from 6
weeks to 6 months).
• Neuromuscular disease:
– Cerebral palsy
skeletal survey with healing left distal radius
and ulna fractures
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Internal injuries
• Whiplash injuries, sub arachnoid, subdural
haemorrhage (shaken baby syndrome)
• Cerebral contusion, bleeding, oedema
• Diffuse axonal injuries
• Neck injuries - contusions
• Chest – haemothorax
• Abdomen- intestinal tears, liver and
spleen ruptures
• Any fatal injury…..
Shaken Baby Syndrome
“Non-accidental head trauma in infants is the
leading cause of infant death from injury. Clinical
features that suggest head trauma (also known as
shaken baby syndrome (SBS) or shaken impact
syndrome) include the triad consisting of retinal
hemorrhage, subdural, and/or subarachnoid
hemorrhage in an infant with little signs of external
trauma.”
Pathophysiology of SBS
Forceful shaking causes shearing of the blood
vessels in the brain, which can further cause
subdural hemorrhage.
Pathophysiology of SBS
• Hallmark Sign: Absence of/or minimal
evidence of external trauma to the
head, face, and neck but serious
intracranial or intraoccular bleeding.
Child sexual abuse
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Rape
Anal intercourse in males and females
Inter crural
Oral intercourse
Grave sexual abuse
Incest
History
• Children rarely lie about sexual abuse
• Any complain by a child of sexual
abuse is to be considered unless
proven otherwise
Examination
• Vaginal penetration causes heavy
bleeding and lacerations
• Attenuation of the hymen with
enlargement of hymenal opening highly
suggestive of recurrent vaginal
penetration
• Hymenal tears – must extend to base,
when healed usually seen as V shaped
notch
• Reddening of labia (pruritus ?)
• Semen sometimes present
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Anal tears, Bleeding
Anal tags and fissures as it healed
Minimal injuries if lubricant is used
Semen may be seen
Repeated penetration results lax anus
with reduced tone
• Inter crural intercourse usually leave no
injuries
• Reddening of inner thigh, perineum or
perianal areas may be seen
• Thickening and pigmentation in
chronic cases
• Semen may be seen
• Oral intercourse may not leave marks
• Forceful penetration causes injuries to
lips, gums, floor of mouth
• Chronic cases ulceration mouth may
be seen
• Semen may be seen
• Kissing, fondling, sucking,
masturbation, touching of genital and
para-sexual areas may not leave any
marks.
• Digital penetration of vagina or anus
may leave bruises and tears.
• Pornography video and photographs
using children (Non contact abuse)
Manifestations suggestive of child sexual
abuse
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Sleep disturbances with nightmares
Night wetting
Discharge PV
Pruritus ani, vulvi
Painful defecation
Recurrent urinary tract infections
Masturbation
Sexual explicitness (play, draw)
Anxiety, eating disorders
Behavioral problems in school
Child labour
• Employ children under 14 years (home
or work place) is illegal
• Often associated with physical abuse,
sexual abuse, neglect and
psychological abuse
• Procurement of armies (Child soldiers)
• Transport of drugs and illicit liquor
Child neglect
Deprivation of care and attention to a
child by their parents or guardian.
• Failure to provide
Adequate food
Clothing and warmth
Proper lodging
Health care
Education
• Exclude
Poverty
Ignorance
Poor education
• Child neglect
Repetition of neglect
Negative consequences of child
heath and development.
Diagnosis
Poor, dirty clothing or naked
Poor hygiene (body, oral, genital)
Overgrown, mattered hair
Head lice
Dirty nails
Features of starvation and malnutrition
Skin infections (scabies, impetigo)
Common respiratory and gastrointestinal
infections
• Worm infestations
• Negligence of health care including
vaccinations
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Psychological abuse
Sustained
repetitive,
inappropriate
behaviour which damages or substantially
reduces the creative and developmental
potential of crucially important mental
faculties and mental processes of a child.
Include
Intelligence, attention, imagination…
Psychological abuse
• Verbal abuse
• Threatening behaviour
• Punishment given excessive
• Intimidation
• Ridicule
• Being rejection and isolation
Features of Psychological abuse
• Depressed mood and other unusual
emotional responses
• Poor eye to eye contact
• Aggressive behavior
• Unusual or unexplainable attachment
patterns with care giver
• Any other physical or psychological findings
which may arouse suspicion
Munchausen’s syndrome by
proxy
Usually mother takes the child to various
doctors and hospitals with bogus
complains of illness which very often
requires extensive investigations sometime
even surgery.
Separation from the mother results
improvement of the child.
Father may unaware the symptoms
Intentional poisoning and
drugging
• To quite the crying child
• To control hyperactive child
• To form Munchausen's syndrome
Child may be given substances of abuse
or sedative medications
Child may be
• Drugged
• Given laxatives to create diarrhea
• Blood added to urine sample….
Diagnosis of child abuse
The most important first step in the
diagnosis of child abuse & neglect is a
high degree of suspicion and prompt
recognition.
Warning signs in the history
Warning signs of examination
Warning signs in the history
Nature of presentation
• Delayed presentation for medical
treatment
• History incompatible with the injuries
seen
• History incompatible with the
developmental age of the child
• Changing history from time to time
Behavioural / psychological
• Deteriorating school performance or
school refusal
• Sudden onset unusual behaviours
• Attempted suicide or deliberate selfharm (older chilid)
• Sexualized behaviour
• Avoiding certain places or persons
• Children with sexually inappropriate
behaviours eg. being unusually friendly
with certain adults
Symptom pattern
Somatic
• Vaginal discharge especially if blood stained
or purulent
• Assumed menarche without sexual
maturation
• Painful defecation with or without bleeding
per rectum
• Skin lesions in the perineum&/or perianal
region
• Somatization phenomena such as headache,
abdominal pain, pseudo- seizures and ect.
Social
• Dysfunctional home environment eg.
Broken families, parent/s employed
abroad, substance abuse among
family members
• Children without adult supervision
• Physical examination
– Evidence of neglect
– Multiple injuries of different stages of healing
– Unusual skeletal injuries
• Long bone fractures in infants(spiral fractures are
very suspicious)
• Metaphysial fractures – chip and bucket handle
fractures
• Posterior rib fractures
– Bite marks
– Burns & scalds eg. cigarette and fire brand injuries,
incense stick burns, immersion injuries, peri-oral scalds
– Association of retinal hemorrhages and finger tip
bruises on the chest eg. shaken baby syndrome
– Foreign body in the vagina
– Multiple anal fissures or patulous anus, skin lesions in
perineum/ perianal region
– Ulcerations in oral cavity& torn frenulum
Diagnosis
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Do not be too dogmatic
Look for risk factors
Exclude differential diagnosis
Do relevant investigations
Medico Legal Evaluation of Victim
of Suspected Abuse
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History
Physical Examination
Laboratory and Radiologic Studies
Differential Diagnosis
Documentation
Risk factors of child abuse
• Multi-factorial
– Child Characteristics
– Parental Characteristics
– Family/Environmental Factors
– Triggering Situations
Look them during history taking….
Risk factors
Child characteristics
• Premature births
• Physical disabilities
• Developmental disabilities
• Chronic illness
• Behavioural problems
• Unwanted child
Risk factors
Parental characteristics
• Psychiatric problems
Low self esteem, depression,
poor impulse control
• Alcohol and substance abuse
• abuse as a child
• Teenage parent
• Single parent
• Unrealistic expectations of child’s behaviour
• Negative view of themselves and their
children
Risk factors
Social factors
• Poverty
• Poor education
• Isolation
• Intimate partner violence
• Unemployment and financial problems
Triggers
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Excessive crying baby
Child’s misbehaviour
Family arguments
Intimate partner violence
Intimate partner violence and
Child abuse
Physical Injuries to Children May Be:
• Accidentally caught in the crossfire
• Intentionally injured while protecting their
mother
• Over-disciplined or abused by stressed,
anxious, and depressed parent
Taking a history from the
caretaker/parent
• Children should not be present
• Interview adults who are present
separately
Physical Examination
• Emergent care first
• Complete head to toe evaluation
• Must look at all skin surfaces
– Remove ALL clothing
– Eyes, Ears, Neck, Mouth, Genitalia, Anus
– Description of all skin findings
Diagnosis of Child Abuse
• Lab tests
– Bruising – Haematological studies
– If fractures, Ca, Phos, Alk Phos
– Consider Vitamin D , PTH and Copper
• Radiology Studies
– Skeletal survey
All children < 2 years of age
2-5 years: selective survey
Consider in children aged 2–4 years with severe bruising.
Older children with severe injuries.
Children dying in unusual or suspicious circumstances.
– Bone scan
– CTs / MRIs
• Ophthalmology
• ENT
• Orthopedic …..
The Skeletal Survey
Skull: frontal and lateral views
Spine: frontal, lateral thoracolumbar spine
(including sternum)
Chest: PA
Extremities:
Upper – AP, Lateral to include shoulders, arms,
forearms and hands
Lower – AP, Lateral to include lower lumbar spine,
pelvis, Femur, Tibia/fibula, feet
Skeletal Trauma
80% cases in children < 18 months of age
• 50% children with fracture due to abuse
have more than one fracture
• Refer radiologist for evaluation
Diagnosis of Abuse
Indications for admission to a hospital:
• Medical/surgical/psychological treatment
that cannot be provided as an outpatient
• To provide a place of safety
Eg . Alleged/ suspected perpetrator living in
the same environment
If parents/guardians refuse admission:
• Medical Officer OPD should inform the JMO
immediately to obtain a court order through
the police irrespective of the time of the day.
Assessment of a physically abused child
• Physical abuse often overlaps with other forms of abuse.
• Abuse may involve other siblings and family members.
• Abuse may recur and escalate.
• Younger children and infants are more at risk of physical
injury and death than older children.
• The aim of recognition and early intervention is to protect
the child, prevent mortality and morbidity, and diagnose
and improve disordered parenting.
• Early intervention in families may prevent more serious
abuse and subsequent removal of children into care.
Health consequences of child abuse
• Physical
Abdominal and thoracic injuries
External injuries
Fractures and disability
ocular and auditory damage
• Sexual
STD
Unwanted pregnancy
• Psychological
Depression and anxiety
Eating and sleeping disorders
Hyperactivity
Poor school performance
Post traumatic stress disorder
effects
Death or disability in severe cases.
• Affective and behavior disorders.
• Developmental delay and learning
difficulties.
• Failure to thrive and growth retardation.
• Predisposition to adult psychiatric
disorders.
• An increased risk of the abused
becoming an abuser.
Medico Legal Management
Medico legal management of
abused child
Aims of Management
• Provide immediate medical care in a
secure environment
• Reduce re-traumatization
• Assess other children who may be at risk
• Work towards holistic recovery
• Prevent further abuse
• Assist legal process for justice
• Objectives of Case Conference:
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To prevent re- victimization
Inform other specialties about the victim
Plan further management
Follow up
• The Procedure the Case Conference
– The JMO is responsible for coordinating the
Clinical Case Conference.
– The decisions will be documented in the BHT
– Date, time & Case Conference will be
decided
– Invite the relevant parties
The participants at the Case Conference
• Medical administrator
• Pediatrician
• JMO
• Psychiatrist
• Relevant medical and nursing Officers from the
Paediatric ward
• Child Probation officer designated as a case manager
• Police officer from the women’s & children’s Bureau of
the police station from the area of residence
• Child Right Promotion Officer
• National Child Protection Authorityofficer of the area
• Community Physician / Medical Officer of Health
• Child, Parents/guardian of the child and any other
relatives when indicated should be present at the time
of the case conference.
• Any other
• Details of child
• Date, time, venue
• Names of attendees with designations and
signatures
• Decision Recommendations
Placement
Medical Management
Psychosocial rehabilitation & re-integration
School / vocational training
Follow up plan
Medico legal investigation
death suspected child abuse
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Detailed history
Scene visit
Identification
Preliminary investigations
Clothing examination
General external examination
Specific external examination
Internal examination
Samples for laboratory investigation
Documentation
Conclusions
Child abuse is very common
Often missed by clinicians
Must have high index of suspicion
Mandated reporters must report suspicion of
abuse
• Complete careful histories and examinations
• Document, document, document!
• Avoid the misdiagnosis of abuse
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Physicians may be involved in a range of child
protection activities,
including the following:
• Recognition, diagnosis, and treatment of
injury.
• Joint interagency activity.
• Court attendance.
• Ongoing care and monitoring of children
following suspected abuse.
• Support for families and children.
• Prevention.
• Teaching, training, supervision, and raising
awareness.
Summary
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Definitions
Injury pattern
History
Examination
Investigation
Medico legal management
Medico legal investigation of a death
• Thank you.