Maria D. McColgan, MD, MSEd
Assistant Professor
Director, Child Protection Program
St. Christopher’s Hospital for Children

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History
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Definitions
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Epidemiology
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Etiology
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Recognition of abuse
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Medical Evaluation
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Reporting and Documenting

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1860 - Ambroise Tardieu
–French physician
–Medical, psychiatric, social and demographic features of child abuse as a syndrome
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1874 – Mary Ellen Wilson 10 y/o
–Removed from home
–Provided protection by NY courts
–Founding of NY society for Prevention of
Cruelty to Children
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1899 – First juvenile court in Illinois

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1912 – FDR helped create US children’s Bureau
1944 – Supreme court confirms state authority to intervene to protect children
1946 – Dr. Caffey (pediatric radiologist)
– SDH and long bone fractures inconsistent with accidental injury
1962 – Dr. C. Henry Kempe
– “The battered child syndrome” in JAMA
– 447 abuse cases reported in 1962
 (2.9 million cases reported in 1992)
– In response the US children’s Bureau recommends child abuse reporting laws
1967 – 44 states adopted mandatory reporting laws

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Terms in National Library of Medicine
– Syndrome of Ambroise Tardieu
– 1964 – “Child abuse”
– 1975 – SIDS
– 1981 – PTSD
– 1987 – “Child abuse, Sexual”
– 1991 – Battered child syndrome
– 1992 – Munchausen syndrome by Proxy
– 1992 – Head injuries, closed
– 2003 – shaken baby syndrome
 1993 – AAP noted term

 A victim is under 18 years of age who has sustained…
– A serious physical, mental, or sexual injury or serious physical neglect as a result of the acts or omissions by…
– A parent, paramour of the parent, person residing in the same home as the child or person responsible for the child’s welfare (at least 14 years of age).
– Any recent (within 2 years) act or failure to act by a perpetrator that creates an imminent risk of serious physical injury to, or sexual abuse or sexual exploitation of a child.

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Consensual intercourse between children within 3 years of age is not illegal
– 15 y/o can consent to sexual intercourse with an 18 y/o
Statutory rape : victim is less than 16 years of age, there is 4 year difference married to each other in ages and they are not
Sexual intercourse with a child less than 13 is rape
– A child less than 13 years old cannot consent to having intercourse
– If one of the children is older than 12 and greater than 2 years difference from the age of the other child, then it can be considered rape
– It is not illegal if both children are less than 12

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National Clearinghouse on Child Abuse and Neglect http://nccanch.acf.hhs.gov/general/legal/statutes/define.
cfm
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National District Attorney’s Office http://www.ndaa.org/apri/programs/vawa/ statutes.html#

Pennsylvania Consolidated Statues
Title 23 § § 6301-6319
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“Persons who…come into contact with children shall report …when they have reasonable cause to suspect that any child, on the basis of their training and experience… is an abused child.”
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While at work, physicians and other health care workers, teachers, pastors

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May be prosecuted for failure to report
Legal immunity is granted to the reporter
Identity of the reporter is confidential.
Informing the parent
– Not required by law
– St. Chris advocates informing the family of the DHS
 If there is a flight risk, involve police and DHS

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Child Maltreatment 2006
USDHHS
– ~ 3 million reports involving 5.5 million children
– ~ 902,000 confirmed cases
– 12.1/1000 children
 18% Physical Abuse
 64% Neglect
 9% Sexual Abuse
Medical personnel - ~8% of reports http://www.acf.hhs.gov/programs/cb/pubs/cm04/index.htm

Abuse
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Psychological 11%
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Physical
(parent)
11%
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Sexual
(anyone)
22%
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Household Dysfunction
Substance abuse 26%
Mental Illness 19%
Domestic Violence 13%
Imprisoned household member 3%

Flaherty, Sege 2005
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Physician recognition of child abuse
– Lack of knowledge
– Psychological barrier to recognition
– Family, racial, economic factors
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Barriers to reporting
– Do not report all cases
– Lack of training on how to report
– Report will harm child
– Poor experience with Child Protective Services
– Poor experience with legal system
– Misunderstanding of MD role

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Parents 80%
Other relatives
6.7%

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Nearly 1530 fatalities
2.04/1,000 children
78% < 4 years old
Infants 18/1,000

Type of Incidence of Incidence of Ratio
Maltreatment Children w/ Children w/o
Disabilities Disabilities
(per 1,000) (per 1,000)
_____________________________________________________
Any Maltreatment 35.5 21.3
1.67
Physical abuse 9.4 4.5 2.09
Sexual abuse 3.5 2.0
1.75
Source: From A Report on the Maltreatment of Children w/Disabilities, U.S. Department of Health and Human Services,
James Bell Associates, Inc., No. 105-89-16300, Westat, Inc., 1993.

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Multi-factorial
– Child Characteristics
– Parental Characteristics
– Family/Environmental Factors
– Triggering Situations

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Child maltreatment
 occurs in 33-77% of families in which there is abuse of an adult
(Garbarino 1992, Wright 1997,
Zuckerman 1995)
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Children of battered mothers
 6 to 15 times more likely to be abused

Physical Injuries to Children May Be:
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Accidentally caught in the crossfire
Intentionally injured while protecting their mother
Over-disciplined or abused by stressed, anxious, and depressed parent

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The Role of the Pediatrician in Recognizing and Intervening on Behalf of Abused Women
– Intervention is crucial because children are also likely to be victims
– Questions about family violence should become part of anticipatory guidance
– Identifying and intervening on behalf of battered women may be one of the most effective means of preventing child abuse

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History
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Physical Examination
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Laboratory and Radiologic Studies
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Differential Diagnosis
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Documentation

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Children should not be present!!
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Interview adults who are present separately
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Triage history often plays a critical role

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Who?
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What?
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When?
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Where?
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Why?
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How?

– Depressed, angry, withdrawn, other changes
– School performance
– Aggressive behavior, temper tantrums
– Behavior with family pets/animals
– Detailed information about adult sexual behavior
– Explicit demonstration of sexual play
– Compulsive masturbation
– Excessive sexual curiosity
– Bedwetting
– New risk taking behaviors

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It is OK not to take a history from the child
– Is the information necessary to make medical decisions?
– Has the child been interviewed already and disclosed?
– Is the child ready to disclose?
– Would this child be better served by a forensic interview?

• History inconsistent w/physical
• Magical injury
• Sibling blamed
• History changes with time or varies between caregivers
• Delay in seeking care
• Self-inflicted injury incompatible w/development
• Poor Parent Child Interaction

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Emergent care first
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Complete head to toe evaluation
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Must look at all skin surfaces
– Remove ALL clothing
– Ears, Neck, Mouth, Genitalia
– Description of all skin findings

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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

ACCIDENTAL ABUSIVE

ACCIDENTAL
Shins
Lower arms
Under chin
Forehead
Anterior thigh
Upper arms
Neck
Face
ABUSIVE
Hips
Elbows
Buttocks
Trunk
Ankles Ears
Bony prominences Genitalia

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Mom found him at bottom of stairs with excersaucer on top of him

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Developmental history – sits with support, does not crawl, does not pull to stand

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Changing histories

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Repeat skeletal survey with healing left distal radius and ulna fractures

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Labs
– Trauma labs
– Bruising - hematology workup
– If fractures, Ca, Phos, Alk Phos
– Consider Vitamin D 25 and 1,25, PTH and Copper
Radiology Studies
– Skeletal survey
 All children < 2 years of age
 2-5 years: selective survey
– Bone scan
– CTs / MRIs
Ophthalmology
Medical photography

Skull: frontal and lateral views
Spine: frontal, lateral thoracolumbar spine
(including sternum)
Chest: frontal
Extremities:
Upper - frontal to include shoulders and hands
Lower - frontal to include lower lumbar spine, pelvis, feet

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2nd most common manifestation of abuse
– 80% cases in children < 18 months of age
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43% unsuspected at time of evaluation
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50% children with fracture due to abuse have more than one fracture

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Abusive fractures often reflect multiple episodes
Younger children (infants) heal faster
4 stages in bone injury

Stage
Induction
Soft callus
Time Characteristics
3-7 days Inflammation, pain, swelling
Infants 7-10 days
Children 10-14
Periosteal new bone formation
14-21 days Union at fx site Hard callus
Remodelling 3 months-1 year
Woven to lamellar bone

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Examine siblings, other children in household
– Twins receive IDENTICAL workup

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Must rule out medical diagnosis other than abuse

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Erythema multiforme – palms/soles initially, extension upwards, can become purpuric
ITP, other coagulopathies
Henoch-Schönlein purpura – normal platelets – IgA – mediated vasculitis – often involves buttocks and lower extremities

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Secondary syphilis
Allergic shiners
Phytophotodermatitis
Cultural practices
– Cao gio (coining)
– quat shat (spooning)
– cupping

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First Degree
Cellulitis, erysipelas
Sunburn
Contact dermatitis
Diaper rash
Drug reaction

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Second Degree
Bullous impetigo
Staphylococcal scalded skin syndrome
(SSSS)
Toxic epidermal necrolysis
Epidermolysis bullosa
Phytophotodermatitis
Psoriasis

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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

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Congenital:
– Osteogenesis imperfecta
– Menke’s syndrome
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Neoplasm:
– Leukemia
– Langerhans cell histiocytosis
– Bony metastases
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Nutritional /
Metabolic:
– Copper deficiency
– Rickets
– Scurvy
– Renal osteodystrophy
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Normal variant:
– Physiologic periosteal new bone
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Infectious:
– Congenital syphilis
– Osteomyelitis
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Neuromuscular disease:
– Cerebral palsy
– Congenital insensitivity to pain
Thompson 2005

Accidental Fractures
Toddler’s Fracture
Accidental oblique fracture of tibia in children 9 months to 3 years of age
Often are unwitnessed injuries of trivial nature
Limp, refusal to bear weight
Localized tenderness may be present, no swelling
X-rays often negative

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Carefully Documented In A Stepwise
Approach
– History –Verbatim Documentation
– Physical – Pictures Are Helpful
– Lab & Radiographic Studies
– Instructions for follow up

– Photographs
 DO NOT need consent for forensic photographs
 Photographs DO NOT take the place of documentation, they support visual cues to the documented description
 Used to appropriately visualize described lesions/marks
 Have a marker, (ruler or coin) within the photograph that can assist with determining size of lesion
 Put the child’s name, date of birth, medical record number, and date of ED visit on the photograph/ diskette

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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