Recognition of Child Abuse for the Mandated Reporter 4e

By Angelo P. Giardino, MD, PhD, MPH, FAAP, Linda Shaw, MD, MSSW, Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN and Eileen Giardino, RN, PhD, APRN, FNP, ANP

434 pages, 70 images, 35 contributors

Health care professionals, including physicians, nurses, and clinical social workers, are required by law and professional codes of conduct to report suspected child abuse. These so called “mandated reporters” need current and practical information to recognize the signs and symptoms of child maltreatment. The fourth edition of Recognition of Child Abuse for the Mandated Reporter has been revised and updated to include contemporary best practices in the evaluation of child abuse and neglect.

The authors and editors of this vital text represent a diverse array of professional disciplines and research interests. Together, they have assembled a multidisciplinary work concerned with a variety of topics essential to the recognition and prevention of child abuse wherever it may occur. These topics include:

— Recognizing and reporting physical abuse, sexual abuse, and child neglect

— Medical child abuse, or Munchausen’s syndrome by proxy

— Risks to children in the digital age, including online predation and sexual Exploitation

— Creative art therapy and its potential benefits to traumatized children

Recognizing and reporting child abuse in the school setting, Recognition of Child Abuse for the Mandated Reporter is a definitive reference for front line professionals seeking to comply with mandated reporting guidelines. In addition, this publication serves as a textbook for students studying medicine, nursing, social work, and law enforcement and who plan to work with children and families in their professional practice. Written by experts on the front lines of child protection, this text details the most effective methods for interviews, examinations, documentation, and appropriate referrals in cases of child maltreatment.

• Language: English
• Publisher: STM Learning
• Release date: Jan 15, 2015
• ISBN: 9781936590360

Angelo P. Giardino, MD, PhD, MPH, FAAP

Angelo Giardino is the medical director of Texas Children's Health Plan, a clinical associate professor of pediatrics at Baylor College of Medicine, and an attending physician for the Texas Children's Hospital's forensic pediatrics service at the Children's Assessment Center in Houston, Texas. Dr. Giardino completed his residency and fellowship training in pediatrics at the Children's Hospital of Philadelphia. Immediately after his fellowship training, Dr. Giardino became the assistant, and then the associate, medical director at Health Partners of Philadelphia, where he had primary responsibility for utilization management, intensive case management, and health care data analysis. He also shared responsibility for the plan's quality improvement program.

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Chapter 1

PHYSICAL ABUSE

John Loiselle, MD

Lauren P. Daly, MD

OBJECTIVES

1.Discuss the definitions of physical abuse.

2.Identify components for determining whether a child has been the victim of physical abuse.

3.Recognize that several conditions and circumstances can mimic abuse.

4.Understand the importance of the presenting explanation for a child’s injuries.

5.Identify barriers that lead to failures in reporting child abuse and neglect.

KEY TERMS

—Abusive burns

—Abusive head trauma (AHT)

—Abusive or intentional injuries

—Battered children

—Coining

—Cold panniculitis

—Common childhood injuries

—Cupping

—Doughnut-shaped burn

—Impetigo

—Intra-abdominal injuries in children

—Lip-lickers dermatitis

—Mandated reporters of physical abuse

—Mimics of abusive injuries

—Physical maltreatment

—Phytophotodermatitis

—Ranula

—Retinal hemorrhages

—Scurvy

—Shaken baby syndrome (SBS)

—Shaken impact syndrome

—Staphylococcal scalded skin syndrome

—Stocking or glove burns

—Stomatitis

—Thrombocytopenia

—Trichotillomania

INTRODUCTION

The most remarkable fact about the physical abuse of children may not be how frequently it occurs but how long it remains an unrecognized or ignored phenomenon.¹,²,³ While the physical abuse of children has almost certainly existed throughout human history, it was not until 1946 that the first formal descriptions of nonaccidental injuries in children began to appear in medical literature,⁴ and not until the 1960s that the occurrence was considered a significant problem.³ Therefore, the study of child abuse, and any resulting detailed descriptions of battered children are relatively new additions to the medical community. Even today, cases of seemingly obvious child abuse are missed.

National statistics on abused children help put the problem of identifying child abuse into perspective. In 2011, approximately 3.4 million reports involving 6.2 million children were made to Child Protective Services (CPS) agencies.⁵ Of these, nearly 61% were accepted as needing further investigation, and after processing, the investigations concluded that 676 569 children had been maltreated, with 17.6% of these cases, or 118 825 children, substantiated for physical abuse.⁵ A child maltreatment report is considered to be substantiated if investigation yields a determination that the child has been abused or is at significant risk of being abused or neglected. Substantiation implies a degree of certainty on the part of the child protective services (CPS) agency that the abuse occurred or that the child is at significant risk of such. The most common form of substantiated abuse in 2011 was child neglect, which accounted for 78.5% of cases, followed by physical abuse at 17.6%, then child sexual abuse at 9.1% of cases.⁵

Using a different methodology than the counting of substantiated cases, the Fourth National Incidence Study (NIS-4) mandated by the US Congress in the Keeping Children and Families Safe Act of 2003 (PL 108-36) provides up-to-date epidemiologic incidence data.⁶ The NIS methodology views maltreated children who are investigated by CPS agencies as representing only the tip of the iceberg (see Figure 1-1). Children investigated by CPS are included along with maltreated children who are identified by professionals in a wide range of agencies in representative communities. The NIS-4 uses data gathered from a nationally representative sample of 122 counties during 1 of 2 reference periods (September 4, 2005 through December 3, 2005 or February 4, 2006 through May 3, 2006). Professionals in these counties serve as NIS-4 sentinels and report data about maltreated children identified by the following organizations: elementary and secondary public schools; public health departments; public housing authorities; short-stay general and children’s hospitals; state, county, and municipal police and sheriff departments; licensed daycare centers; juvenile probation departments; voluntary social services and mental health agencies; shelters for runaway and homeless youth; and shelters for victims of domestic violence. Looking at the most severe cases defined as the Harm Standard in the NIS-4, an estimated 1.25 million children were maltreated in the 2005-2006 reporting period, with 323 000 children being victims of physical abuse. So, the actual number of children who are physically abused likely rests somewhere between the 118 000 cases counted by CPS and the 323 000 cases estimated by NIS-4.⁶

Figure1-1

Figure 1-1. Levels of Recognition for Child Abuse and Neglect. Reprinted from Sedlak AJ, Mettenburg J, Basena M, et al.⁶

As reported by Selby,⁷ health care providers in the United States favor the history of abusive or intentional injuries as reported by a caregiver rather than the more obvious explanation for the injuries in 1 of 10 cases, though expert forensic pediatric providers have been shown to differ in their evaluations of the etiology of the same child’s condition.⁸ Additionally, a lack of standard protocols for dealing with suspected child abuse⁹ and legally enforceable mandatory reporting mechanisms among hospitals and institutions further facilitates opportunities for missed diagnoses and makes early recognition and identification of child abuse much less likely.

For 2011, the National Child Abuse and Neglect Data System estimated 1570 children (2.10 per 100 000)⁵ died as a result of abuse or neglect, whereas NIS-4 estimated 2400 children died during 2005-2006 time period.⁶ The number of child fatalities from abuse and neglect is believed to be higher than statistics show. The causes of child fatalities are not accurately captured by vital statistics due to misclassification or poor death investigation.¹⁰,¹¹

In a 2001 to 2002 nationwide sampling of more than 15 000 adolescents, more than 1 of 4 participants reported being the victim of physical maltreatment, defined as being slapped, hit, or kicked by a parent or caregiver before reaching the age of 12 years.¹² Studies have found that children severely injured or killed as the result of physical abuse were the victims of previous suspicious injuries for which the opportunity for identification was missed.¹³-¹⁸ The missed opportunity for identification of potential abuse bares particular weight as victims of abuse who do not come to the attention of social services are at substantial risk for ongoing and escalating episodes of abuse.¹⁶ A study of nationally representative data indicated that gender, racial and ethnic status, history of physical abuse in childhood, and households where violence or drug use is witnessed place children at risk for continued physical assault.¹⁵ Additionally, exposure to violence has been associated with both negative physical and mental outcomes in adulthood.¹⁸ (See Figure 1-2 for incidences of different types of maltreatment.)

Figure1-2

Figure 1-2. Types of Maltreatment. Reprinted from United States Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.⁵

CHALLENGES FACING MANDATED REPORTERS

The designation of mandated reporter of physical abuse is one made by each state and encompasses individuals legally required to report suspected cases of abuse within the boundaries of the individual state. The importance of identifying abused and neglected children is clear; still, the mandated reporter faces a number of challenges, even barriers, in fulfilling this obligation, including anxiety associated with making what some may consider a harsh accusation and personal barriers that may prevent the consideration of physical abuse as a possible cause for an injury. While some factors place a child at greater risk for abuse, and some injuries are more indicative of abuse than others, it is important that reporters be cognizant of the facts that abusive injuries can occur in any child, any family, and any culture, and almost any injury can be nonaccidental in nature.

Defining Physical Abuse

One major challenge facing the mandated reporter is the lack of universal understanding regarding what constitutes physical abuse. Individuals, institutions, and health care specialties all offer differing opinions as to what findings meet the criteria for a diagnosis of physical abuse. The Child Abuse Prevention and Treatment Act (CAPTA) was enacted in 1974 and defines abuse as any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.¹⁹ Still, this description only provides a minimum standard and a mandate for states to incorporate the standard into their individual child abuse statutes and does not specifically define physical abuse.¹⁹ Under CAPTA, it is expected that state law will vary with respect to the specificity of the definition of child abuse, the age of the child subject to abuse, who may be considered a perpetrator, and what degree of injury is considered abuse. Documents detailing state legislation with definitions of child abuse and neglect are listed in various documents available online through the Child Information Gateway (http://www.childwelfare.gov).

Without a clear definition of physical abuse, the nature of many acts remains ambiguous and leaves the mandated reporter with many unanswered questions regarding the boundaries of discipline, characteristics of an abusive injury or an injury resulting from neglect, and severity threshold that must be met in order for an injury to be considered abusive. Current definitions often leave these areas open to individual interpretation. The laws in 14 states provide exceptions for physical discipline that is considered reasonable or moderate and does not result in injury.¹⁹ The American Academy of Pediatrics (AAP) provides additional guidance and consistency by defining abusive skin injuries as any injury beyond temporary redness of the skin and any injury that lasts more than 24 hours.²⁰ Even with this clarification, in many instances, an abusive injury cannot be distinguished from unintentional injury by appearance alone. The bruise a child sustains on the forehead after stumbling on the sidewalk can be indistinguishable from one sustained after being thrown to the sidewalk by an angry caregiver. Additionally, a number of medical conditions may give the appearance of abusive injuries, further complicating the identification process.

The difficulties facing mandated reporters, especially the lack of available information and education, create a seemingly insurmountable obstacle of ambiguity that has the potential to create feelings of inadequacy with regard to reporting abuse. However, simply working with young children as a professional provides valued experience required for a mandated reporter to become familiar with the characteristics of certain common childhood injuries and abusive injuries, including expected locations, frequency, patterns, and severity.

This chapter will review a number of the characteristics of abusive injuries, but it must be noted that the identification of abuse does not typically rely on the evaluation of physical findings alone. Discrepancies between the explanation provided for an injury and the logical cause of the injury are often crucial to the diagnostic process (Table 1-1). The explanation of an injury or physical findings can signal the possibility that abuse has occurred, but a combination of information is more likely to raise concern to the threshold of reporting. In more complex cases, laboratory tests or imaging studies can also heighten suspicion of abuse.

Medical Conditions that Mimic Physical Abuse Injuries

Numerous medical conditions mimic abuse injuries. Although many are discussed here, it is not the obligation nor often within the abilities of the mandated reporter to know, consider, and exclude every possible alternative explanation for a suspicious injury. This task is more appropriately left to a forensically trained health care specialist. The likelihood that one of many confounding conditions might be responsible for a particular physical finding should not overshadow the concern of possible abuse nor paralyze the mandated reporter to inaction.

Understanding the Role of the Mandated Reporter

The mandated reporter is neither required to act as a detective and track down additional evidence of abuse nor actively seek out abuse or find reasons to fit injuries into a category of abuse but instead has the responsibility to be aware of and remain alert for the possibility of abuse. Only a suspicion of abuse, which falls well below the level of proof, is required to make a report. A recent survey of pediatricians in Pennsylvania found a wide variation in what is considered reasonable suspicion.²¹ The individual who initially reports suspected cases of abuse is rarely the deciding factor in such cases and it is important to note that it is not that individual’s responsibility to provide the level of proof required to solidify any given case, but instead to simply report suspicious findings.

Multiple levels exist in the evaluation of child physical abuse, each providing an additional layer of knowledge and sophistication. Mandated reporters comprise the foundation of the process. For example, the schoolteacher who reports a suspicious mark on a pupil gains the assistance of the local division of child protective services (CPS), which can then involve a forensically trained health care provider to assess the injury and access additional subspecialists or conduct further studies of their own as necessary. Specially trained social workers or police can also perform interviews or investigate the home environment.

When faced with a child who has a questionable physical injury, the reporter may find it helpful to ask a number of questions:

—What about this injury makes it seem out of the ordinary?

—Does the explanation for this injury seem plausible?

—Does the explanation fit the physical findings?

—Was this explanation compatible with the child’s developmental capacity?

—What psychosocial factors may place this child at increased risk for abuse?

One goal of this chapter is to assist the reporter in answering additional questions, such as:

—Are there features of this injury that are consistent with common mechanisms of abuse?

—Are there characteristic findings or patterns that suggest this was an abusive injury?

—What other conditions might explain these findings?

—What further evaluations would be helpful in distinguishing abusive from unintentional injuries?

Not everyone who cares for children is an expert in identifying physical abuse, but knowledge of common childhood injuries and childhood development is acquired as a result of working with children on a regular basis. This knowledge is critical in identifying injuries that are out of ordinary experience. Often, a simple gut feeling that something is not right provides the first clue that an injury may be the result of abuse. Acting on that feeling can lead to the appropriate identification of an abused child and potentially help the child and family.

IDENTIFYING PHYSICAL ABUSE

SKIN INJURIES

The skin is a common site for injury in children. A range of insults may result in marks that vary in shape, color, pattern, and location and occur in the form of bruises, burns, or bite marks.

Bruises

Bruises are the most frequent finding in cases of physical abuse. Bruising raises suspicion of child abuse when it occurs at an unusual age, in uncommon locations, with excessive frequency or severity, or in specific patterns (Table 1-2). Appropriate explanations for accidental bruising should account for the developmental abilities of the child and the amount of force necessary to generate such injuries.

Accidental Injury

Bruising is a manifestation of the rupture of small blood vessels beneath the surface of the skin. Bruising can occur spontaneously in certain medical conditions, but it is usually the result of blunt trauma or sheering pressure applied to the skin. Although accidental bruising can occur in any region of skin, it predominantly occurs in areas with an underlying bony prominence. In the normal course of a child’s play, the areas most likely to be affected by bruising include the shins, knees, forehead, forearms, hands, and elbows. Less frequent, but not unusual, areas of accidental bruising include the hips, cheekbones, and backbones.²²

The most common mechanisms for unintentional bruising are falls or collisions with a stationary object, with age and developmental level being key determinants as to the nature of the bruising. To sustain a bruise, a child must first possess the mobility and developmental skills needed to generate sufficient force against an object. Most 3-month-old infants do not yet have the developmental capacity to roll over and, therefore, cannot sustain bruises on the face from rolling off the bed. Children begin to walk with support, or cruise, around 8 or 9 months of age, thereby increasing their risk for bruising injuries to the chin, nose, and forehead as a result of falls. Bruising is rare in children who have not yet reached cruising age and should be regarded with suspicion.²²,²³ When aged 2 years, children begin to run and climb, and bruising about the shins, forearms, and forehead becomes a common occurrence. As children grow older, a greater number of bruises are likely to be found at any one time, with injury being most common from ages 5 to 9.²² Figure 1-3-a and Figure 1-3-b illustrate both accidental and abusive bruising.

Figure1-3-a

Figure 1-3-a. Pattern of bruising suggestive of abuse. Reprinted with permission from Giardino A.²⁴

Figure1-3-b

Figure 1-3-b. Pattern of predictable accidental bruising. Reprinted with permission from Giardino A.²⁴

Abusive

Bruising from abuse can occur as the result of being slapped, punched, kicked, pinched, or struck by an object. Hands, belts, electric cords, switches, paddles, and broom handles can all be used to inflict intentional harm and can leave a distinctive mark on the skin. For example, a cord that is folded over on itself can produce an elongated U shape known as a loop mark, while a switch can produce 2 parallel red streaks with a central linear pale strip resembling a train track (Figure 1-4-a, Figure 1-4-b and Figure 1-5). Bruises inflicted as a result of striking the skin with an object at high velocity may leave an outline of the object as the impact forces blood to the periphery and capillaries are disrupted on the outer edges of the object.²⁵ Bruises with a linear edge or sharp corner are consistent with trauma from a solid instrument (Figure 1-6). A belt buckle may inflict bruising in an identifiable shape corresponding to the buckle itself. A pinch or tight grasp may leave a pattern of bruising the size of fingerprints, while a slap may leave linear red streaks outlining the shape of the fingers in a recognizable pattern (Figure 1-7). As most individuals are right-handed, the majority of intentional wounds inflicted by a slap are located on the child’s left cheek.²⁶ When the perpetrator faces the child during an assault, the resulting marks are typically oriented horizontally or angled from the chin to the temple. Ligature marks on a child who has been forcibly restrained may appear circumferentially around the wrists, ankles, or neck in the form of bruises or abrasions, depending on the material that was used (Figure 1-8).

Figure1-4-a

Figure 1-4-a. Loop marks from a cord that was rolled up. The dark coloration indicates these are old injuries. Note the parallel lines outlining the shape of the cord.

Figure1-4-b

Figure 1-4-b. Fresh loop mark above the buttock associated with scratch marks and bruising of the buttocks.

Figure1-5

Figure 1-5. Switch marks left on the back of a young child who was disciplined for difficulties related to toilet training. Train track markings are evident.

Figure1-6

Figure 1-6. Pattern bruise on the produced by a wooden backscratcher that was subsequently recovered from the house.

Figure1-7

Figure 1-7. Slap marks on the left cheek of a young child. The linear, dark red areas correspond to the space between fingers.

Figure1-8

Figure 1-8. Circumferential bruising of wrist caused by restraints.

Children who are abused are more likely to be struck in certain locations on the body. Corporal punishment is customarily delivered to the buttocks. This is an area with a high proportion of subcutaneous tissue and is normally covered with protective clothing, especially in young children still in diapers; therefore, the buttocks are relatively protected in the normal course of a child’s day. Bruising here is unusual except when intentional (Figure 1-9). The face is another common site to strike a child. Extensive bruising that occurs on both sides of the face is especially difficult to explain from a single fall. Additional common sites for abusive bruising include the outward aspect of the forearms, back of the hands, chest, thighs, and abdomen. For example, a child may sustain injuries to the outward aspect of the forearms or the back of their hands while raising his or her arms in self-defense (Figure 1-10). Bilateral bruising on the upper arms suggests the child has been forcibly grasped in this area (Figure 1-11).

Unintentional bruising is more likely to occur as a single injury; therefore, bruises that occur at typical sites but in excessive numbers or are unusually large are also indicative of abuse. Even young children do not voluntarily repeat an experience painful enough to inflict a bruise. Clustering of bruises is typical of a child who has been struck multiple times.²⁷

The process of estimating the age of a bruise based solely on color is not as precise as once thought. Previously published tables suggesting the color of a bruise progresses over time through a predictable, orderly change were found to be based on minimal evidence and are no longer considered authoritative.²⁸,²⁹ While the presence of a welt or raised area below the bruise suggests a recent injury, no completely reliable method exists to determine the age of a bruise. Recent investigations have demonstrated that all the colors typically found in bruises can appear in fresh as well as old bruises.³⁰ Even experienced physicians are unable to accurately estimate the age of a known bruise to within a day of its occurrence.³¹ Despite this difficulty, it is still important to document the color, as well as any other details, of each bruise.

Figure1-9

Figure 1-9. Extensive severe bruising delivered with a wooden paddle on the buttocks.

Figure1-10

Figure 1-10. Bruising on the back of the hands from being slapped. Linear red streaks and marks on both hands typical of slap marks.

Figure1-11

Figure 1-11. This child was violently grasped around the upper arm leaving this typical pattern of bruising. She also has bruising around the eye and chest.

BURNS

Abusive burns occur in 6% to 20% of physically abused children.³² In the United States, burns by tap water are the most commonly reported. Abusive burns in young children have been associated with lower socioeconomic status, lower levels of completed education in caregivers, and lack of supervision.³³ It is important for the mandated reporter to develop an appreciation of the different characteristics of typical accidental and abusive burns. Both the depth and extent of a burn depend on the heat of the object, the duration of contact, and the characteristics of injured body surface. Since a child’s sense of pain is well developed at an early age, children and infants alike will rapidly withdraw a hand or attempt to escape a source of heat, meaning that the duration of contact for most unintentional burns is very brief.

Accidental

The natural inquisitiveness of children predisposes them to accidental burns, with scalding and contact with hot surfaces constituting the majority of these injuries. Most children can reach for and grasp objects by the age of 5 months, allowing for potential injury-causing actions to occur, such as tipping over a cup of hot liquid while sitting on an adult’s lap. Infants cannot crawl to an object until approximately the age of 9 months and, still, an abundance of opportunities for unintentional burns exist. Accidental burns resulting from an infant inadvertently touching a hot object or spilling a hot liquid display certain characteristics suggestive of their cause. For example, large circular patches of burns surrounded by smaller satellite burns with an overall triangular shape to the bruise supports a history that a child pulled a hot liquid onto him or herself. The face, chest, and abdomen are most frequently affected in such cases, so a scald burn on the back is not as consistent with a history in which the child is described as having pulled a hot liquid down from the counter.

Figure1-12

Figure 1-12. A typical partial-thickness burn on the palm of the hand of a toddler who reached out and touched a hot iron.

Burns occurring as a result of a child inadvertently touching a hot object usually occur on the fingertips or palm of one of the hands (Figure 1-12). A child instinctively withdraws after touching or grasping a hot surface, so such burns are rarely deeper than partial-thickness. Brief contact with a falling hot object will produce a burn with a less distinct edge than will occur with prolonged intentional contact. Additionally, an instance in which a child brushes against a lit cigarette will produce a superficial or partial-thickness burn in a comet-tail configuration. Burns on the back of the hand, deeper than partial-thickness, or involving both hands are suspicious for abuse.

The AAP recommends home hot water heaters be set to deliver water at a maximum of 49°C (120°F) in order to reduce the risk of hot water burns.³⁴ At this temperature it takes 5 to 10 minutes of contact to produce a partial-thickness burn (one that blisters) in an adult; however, an infant’s skin is thinner than an adult’s, and young children can become severely burned after only 15 seconds of exposure to liquids above 54°C (130°F). Liquids near boiling, such as tea or coffee, cause burns within 1 second.³⁵ Circumferential burns typically seen with immersion burns may occasionally occur unintentionally on the hand of a curious toddler who tests a hot liquid. This type of burn occurs only on the reaching hand and not bilaterally or on the lower extremities.

Abusive

A child may also be burned rolling against a hot curling iron or falling against a heater or radiator. Although the question of adequate supervision or reasonable precautionary measures may arise, such injuries are not typically considered abusive. The child who rolls against a hot object such as a radiator and is unable to extricate himself is at risk for sustaining much more severe burns. Such episodes are rare though and should, in most cases, trigger a report of suspected abuse. A cigarette pressed forcefully against the skin leaves a small circular burn approximately 1 cm in diameter, which is often partial- or full-thickness. Typical locations for cigarette burns include the dorsum of the hands, feet, or face.

Hot grease or oil spills can cause deeper and more extensive burns, since these fluids maintain contact with the skin longer and do not cool as rapidly as water-based liquids. Most splash or spill burns have only a brief period of contact with the skin. In some instances, absorbent clothing may prolong the length of time the liquid is in contact with the skin and increase the severity of the burn, while in other instances, clothing may actually provide protection. For example, a diaper may prevent hot liquid from reaching the covered area in a small child. Scald burns located over the buttocks or genital area in a child in diapers, for which a history of a spill has been given as the purported cause, should raise concerns of abuse. A scald burn forms sharp edges only where it borders an area protected by clothing.

Abusive burns can occur from forced immersion in hot water or forced contact with a hot object. These actions are often intended as a form of punishment or discipline. For example, a caregiver might punish a child with dirty hands who has stained an article of clothing or furniture by holding the child’s hands in scalding water. The toilet training period can be a particularly trying time for parents and can result in a commonly occurring scenario in which a child who has repeatedly soiled his or her diaper is punished by being forced into an excessively hot water bath. The resulting stocking or glove burns are circumferential in shape, located on the hands or feet and demonstrate a discrete area of demarcation indicating the point of contact with the water (Figure 1-13). When a body part is immersed, predictable areas remain relatively protected from the scald. A flexed elbow or knee will protect areas of skin that remain in contact with each other. Only skin surfaces that are exposed to the excessively hot water will sustain burns. The classic doughnut-shaped burn is a pattern of burn injury that occurs when a child is forced into a bathtub of hot water (Figure 1-14-a, Figure 1-14-b, and Figure 1-14-c). The ceramic surface of the bathtub does not conduct heat rapidly, so even the submerged portion of the ceramic remains cooler than the water itself. When the child is forced into a bathtub of hot water, the buttocks and heels come in contact with the ceramic surface and are relatively protected from the hot water. The skin surfaces surrounding the buttocks come in contact with hot water and are burned, leaving a doughnut-shaped pattern.

Figure1-13

Figure 1-13. Full thickness burns of the legs occurring in a stocking distribution on a young child who was forced into a bathtub of hot water. The soles of both feet appear relatively spared because of the thickness of the skin in this area. Note the sharp upper edge of the burn marking the high level mark of the water.

Figure1-14-a

Figure 1-14-a. Doughnut immersion burn pattern on a child forced into a bathtub of hot water.

Figure1-14-b

Figure 1-14-b. Doughnut immersion burn pattern on a child forced into a bathtub of hot water.

Figure1-14-c

Figure 1-14-c. How the doughnut pattern of immersion burns is produced.

The palm and sole often appear relatively uninjured and blister less readily than the surrounding skin surfaces despite similar exposure due to the thickness of the skin covering these areas. Caregivers frequently attribute abusive scald burns to the child climbing into a bathtub and turning on the hot water autonomously, but it is important to remember that children do not have the ability to climb into a bathtub until the age of at least 10 months and lack the motor ability to accomplish this task until the age of 1½ years of age.³⁶ Abusive contact burns are often a means of punishment, and the location of the resulting injury often reflects this motive. A child’s hands may be held against a hot object such as a stovetop or iron as punishment or, sometimes, as a misguided effort to teach the child not to touch these items. Abusive burns may also be found on the backs of the hands or buttocks and typically imprint the shape or form of the object used (Figure 1-15). A geometric pattern or straight edge differentiates these lesions from a standard scald burn. (See Table 1-3).

BITES

Accidental

From the time their teeth first erupt, children can be found testing them out on various objects and, at times, on other children. Children commonly bite the face as part of an attempted kiss or a misplaced hand, though any body part within reach may be at risk. A bite from a child will leave a circular ring of teeth marks (Figure 1-16). Most bites are superficial, but can occasionally draw blood. Dogs and other animals can also cause accidental bite wounds, with the face and lower extremities among the most common location for injury. Dog bites result in puncture wounds and tearing lacerations caused by the animal’s long canine teeth.³⁷

Figure1-15

Figure 1-15. This contact burn with a geometric pattern was not consistent with the reported story that the child had spilled a cup of hot tea on himself.

Figure1-16

Figure 1-16. This child has a toddler bite on the forearm. The circular pattern is typical of a human bite and the small size is consistent with a wound from a young child.

Abusive

Bites intentionally inflicted on a child by adult are often a form of punishment or sexual stimulation. Certain characteristics help differentiate abusive bites from accidental animal or child bites, such as the presence of ecchymosis, more commonly known as a suck mark or hickey, in the center of the bite; involvement of the back, buttocks, or genitalia; and a circular pattern indicative of human dentition. The distance between the canines in an adult bite mark with 12 year molars evidenced is greater than 3 cm, while that of a child younger than 8 years of age with primary teeth is less than 3 cm apart. Careful measurements of bite marks are useful in making this distinction. Referral and evaluation by a forensic dentist can help provide detailed information regarding the source of a bite injury. DNA evidence from the perpetrator might be recovered by swabbing the margins of a recent bite.

HEAD INJURIES

Brain and Skull

The leading causes of traumatic brain injury in children younger than 2 years of age are motor vehicle crashes, falls from great heights, and abusive head injuries. Head trauma is the leading cause of mortality in child abuse.³⁸ Substantial force is necessary to cause traumatic brain and skull injury. It is important to know which scenarios result in serious intracranial injuries and which do not. Forces associated with common childhood play and falls cannot produce the same pattern or severity of injury seen in abusive head trauma (AHT). Childhood injuries resulting from falls down stairs or off beds have been found to have predictable patterns of bruising and occasional fractures,³¹,³⁹ while injuries resulting from short vertical falls of less than 1 to 2 meters have been found to have not resulted in injury for the infant in the vast majority of cases, with the minority having skull fractures and none having intracranial bleeding.³¹,⁴⁰

Depending on the severity of the injury, and especially when presented with a false history, abusive head trauma may not be obvious to the practitioner. When analyzing cases of abuse initially missed by physicians, research has found the cases most likely to be missed involve patients who are very young, white, from intact families, and who demonstrate an absence of seizures or breathing problems. An especially disconcerting study found that children in such initially missed cases are often reinjured or killed.¹³

Accidental Injury

Common mechanisms, including falls from the arms of a caregiver, from a car seat left on a table, or from a bed onto a hard surface, can result in accidental head injuries in young infants. Skull fractures resulting from these unintentional mechanisms are usually linear and not associated with significant intracranial injuries or retinal hemorrhages. Additional injuries such as subdural and retinal hemorrhages can result from birth. Initial studies found a small percentage (8%) of subdural hemorrhage and a greater percentage (20% to 30%) of retinal hemorrhages to have resulted from childbirth,⁴⁰ while subsequent studies found 61% of subdural hemorrhage and 33% of retinal hemorrhages to be birth-related.⁴¹ Severe unintentional trauma as well as specific medical conditions may also produce retinal hemorrhages; however, retinal hemorrhages are highly indicative of abusive head trauma, occurring in 50% to 100% of cases.⁴²

Abusive Head Trauma (AHT)

Shaking has been the mechanism most commonly recognized as the cause of AHT in infants. The brain is subject to severe acceleration-deceleration and rotational forces when a child is held by the trunk and shaken vigorously back and forth.⁴³ Violent rotational forces stretch and break blood vessels around the brain and can cause bruising or even tearing in portions of the organ.⁴³ The injuries sustained from this action comprise what was previously known as shaken baby syndrome (SBS). SBS describes several injuries frequently found together, including intracranial bleeding, brain injury, and areas of bleeding within the back of the eye known as retinal hemorrhages.

Some controversy has existed as to whether the injuries incurred with this syndrome require additional impact of the head onto a surface at the end of the shaking; therefore, giving rise to the term shaken impact syndrome. Studies suggest that a sudden deceleration resulting from the impact of the head against a surface produces many characteristic features seen in cases of AHT. In this scenario, the injury to the brain and surrounding blood vessels results from the internal forces generated by the rapid deceleration and not from the impact itself. A hard surface is not required to produce the necessary deceleration, and infants with internal injuries may have minimal or no external signs of trauma.⁴⁴

AHT victims are usually younger than 1 year of age, but cases involving children as old as 7 years have been reported.⁴⁵ The heavier a child, the more unlikely a perpetrator would be able to manipulate the child’s body to create the necessary forces to sustain injury.⁴³

External scalp injuries, including bruising, swelling, and lacerations, may accompany internal injuries associated with shaken impact syndrome but are not frequently present. Spinal cord injuries, especially at the craniocervical junction, have been observed frequently enough to suggest the health care provider should consider a magnetic resonance imaging (MRI) evaluation of both the head and upper cervical spine.⁴⁶ Many of the instances of spinal cord involvement represented injuries without radiographic abnormality and as such would be missed by plain radiography. A significant proportion of shaken babies present with fractures, the most characteristic types being metaphyseal fractures and rib fractures. Additionally, victims may exhibit breathing abnormalities, seizures, unexplained vomiting, depressed levels of consciousness or tone, or full cardiac arrest. In contrast to other episodes of severe head injury, cases of AHT lack a clear history to explain the mechanism of injury.

While retinal hemorrhage may result from birth, such a finding is most often indicative of abuse. Trained ophthalmologists can help to distinguish unintentional retinal hemorrhages from those caused by abuse based on the location and extent of the hemorrhages.⁴² From the perspective of the mandated reporter, all cases of retinal hemorrhage seen in a child with head trauma should be evaluated for child abuse. Ophthalmology consultation should be obtained when there is a question of shaken baby syndrome or presence of retinal hemorrhages. Similarly, while a skull fracture may result from accidental circumstances, multiple skull fractures, eggshell or complex fractures of the skull, and skull fractures associated with other injuries are highly suggestive of abuse.

Interventions

The responsibility of conducting a more detailed investigation of head trauma and determining its relation to abuse lies with the evaluating physician. A computed tomography (CT) scan of the head and a skeletal survey are recommended in the acute evaluation of any child with suspected AHT. An MRI is recommended for neurologically asymptomatic physically abused children, especially those younger than 1 year of age, to evaluate for occult head injuries.⁴⁷ Follow-up MRI studies may be useful in identifying the full extent and age of the head injury. An infant with intracranial hemorrhages should have an ophthalmologic examination as a routine part of the evaluation to inspect for the presence of retinal hemorrhages.

Outcomes

The long-term outcome of infants with AHT is very poor. Mortality rates have been reported up to 35% among infants, which is higher than that of unintentional head injuries in this age group.⁴⁸ As many as 96% of children with AHT are abnormal on follow-up, with deficiencies including developmental delay, seizures, speech deficits, visual problems, and behavioral problems. As many as half are permanently disabled and require permanent nursing care.⁴⁹

Hair Loss

Accidental

Several mechanisms can result in unintentional hair loss in children. For example, young children, especially young girls with long hair, may habitually twirl or chew on their hair, causing patches of hair loss, a condition known as trichotittomania. Such hair loss typically occurs on the side of the nondominant hand. Tight hair wraps or braiding may also result in a predictable pattern of hair loss. Infants who lie on their backs may develop areas of hair loss on the back of their heads, over the occipital bone, from constant friction. Additionally, hair loss can also occur as a result of untreated ringworm.

Abusive

Hair loss can result from abusive actions. Adults can pull out clumps of a child’s hair when grabbing or pulling the child. This action typically leaves broken hairs and an area of redness and tenderness on the scalp. If sufficient force is applied, a hematoma can occur. In other cases where less force is employed, the findings may be indistinguishable from trichotillomania.⁵⁰ Patchy hair loss should raise a suspicion of physical abuse if the child has not been observed excessively playing with his or her hair.

Mouth

Accidental

The mouth is a common location for both accidental and abusive injuries. The vast majority of unintentional injuries to the face, mouth, and teeth occur once the child is capable of taking steps. The relatively large head size and poor balance of a child predispose them to frequent episodes of falling forward at this age. Bruising of the forehead, nasal abrasions, bloody lips, scraped chins, and dental injuries are often part of the normal costs of learning to walk. Parents frequently reprimand children for running with an object, such as a straw, lollipop, or pencil, in their mouths because the predictable end result of a fall is a tear or puncture wound to the mouth or throat. The teeth with the surrounding soft tissues, especially the frontal incisors, are prime targets for injury from a forward fall. In the process of striking his or her chin, a child often lacerates the area of the tongue that is able to extend beyond the incisors. As the child becomes older and more involved in organized sporting activities, the mouth is at risk from wayward elbows or balls. Children also sustain a large proportion of orofacial injuries as the result of bicycle mishaps.

Abusive

Abusive injuries involving the mouth are often the result of a frustrated caregiver forcing a bottle, spoon, or pacifier into the mouth of a crying infant. The infant might sustain bruises on the lips and cheeks in a circular pattern that matches the pacifier or bottle lid. Repeated thrusts with these objects can inflict bruises or cuts on the hard or soft palate. The frenulum of the upper lip is a thin band of skin that connects the upper gums with the upper lip. The frenulum of the tongue connects the underside of the tongue with the floor of the mouth. While the upper frenulum is commonly injured in simple falls, it is unusual to find unintentional tears of the frenulum of the tongue. Neither structure is likely to be injured unintentionally in a child who is not yet walking.

Direct blows to the face or mouth inflict injuries that can be difficult to distinguish from those sustained in a fall. For example, both accidental and abusive trauma can result in a fracture or dislodge a tooth (Figure 1-17). In both instances, the frontal incisors are most often affected, because of their prominent location. Injuries that are considered suspicious include those with associated slap marks on the face or facial and oral injuries out of proportion to a simple fall. Jaw fractures are rare in young children and require a degree of force not typically encountered in a short fall. A perpetrator wearing a ring may inflict telltale lacerations when punching or slapping the child in the face. A suspected abuser may show injuries to a hand or fist that has come in contact with the child’s teeth. A child who has been gagged or had tape applied over his or her mouth may show patterned bruising in the corners of the mouth or abrasions in areas where the tape has been forcefully removed. The use of alternate light sources in forensic settings may help to identify trace evidence remaining on the skin. Tiny burst capillaries, or petechiae, may appear on the face of a child who has been gagged or strangled. Forced oral sex can produce bruising of the mouth and palate.⁵¹ Oral injuries in the preambulatory child and injuries deep within the mouth that have been attributed to a simple fall and do not include the presence of a penetrating object are indicative of abuse.

Figure1-17

Figure 1-17. Bucket handle fracture of the proximal tibia.

BONE INJURIES

The bones of an adult have many of the same properties of a large stick or branch, possessing intrinsic strength but little flexibility. When sufficient force is applied, the bone of an adult eventually breaks or fractures. The bones of a child more closely resemble saplings, possessing greater malleability and a tendency to bend or fold before breaking. Because of these unique properties, the bones of a child are able to accommodate a wide range of forces that would otherwise break the bones of an adult. For the forensic health care provider, understanding the damage sustained by a child’s bone provides information about the force that was applied as well as how and when it was applied.

Accidental Injuries

The incidence of accidentally broken bones in young children parallels that of bruises. Fractured bones in preambulatory children are rare, and when they do occur, they are often associated with motor vehicle crashes or a significant fall while in the arms of a caregiver. As children increase in their mobility, so does the frequency of unintentional broken bones, which occurs in stepwise increases as the child graduates from walking to running to bicycle riding. The peak incidence of fractures in childhood occurs with the onset of participation in competitive sports.

Bone injuries reflect the mechanism involved in their creation. An experienced orthopedic surgeon, emergency physician, or sports trainer can accurately predict the likelihood and type of fracture simply by listening to the details of the incident. The associated history behind the injury is, therefore, critical in determining the level of concern for abuse. Most unintentional fractures have a clear, consistent story, and many have witnesses as well. Fractures from abuse often have a history that changes, is nonsensical, or associated with a delay in seeking care.

Abusive Injuries

In moments of extreme rage or loss of control, an adult may handle a child in a manner that can injure the bones. In terms of risk for abuse-related fracture, age seems to be the most important factor. Children younger than 1 year of age sustain 55%-70% of all inflicted skeletal trauma. A full 85% of abuse-related fractures occur in children aged 3 years or younger.⁵²

Among abused children, fractures of the extremities are the most common bone injury, followed by skull fractures. Broken bones that result from abusive mechanisms may have predictable findings, as demonstrated by Table 1-4, while the following fracture patterns offer insight to the forces applied to bone:

—Transverse or greenstick: bending; direct impact with an object

—Spiral: twisting

—Buckle: bending

—Metaphyseal: violent shaking, grabbing, yanking, or twisting

Figure1-18

Figure 1-18. This spiral fracture of the femur in a 5-month-old infant required a great deal of force in a twisting motion and was inconsistent with the explanation that the child rolled over on the leg funny.

Extremity fractures in and of themselves cannot be used as definitive evidence of abuse; however, the classic metaphyseal lesion, a plate-like separation of bone through the region of the metaphysis that lies against the physis, in a young child is highly concerning (Figure 1-18). The anatomy of the bone and its covering layer are such that the fracture involves a thin plate of bone in the center and a thicker ring of bone at the edges.⁵³ The classic metaphyseal lesion most commonly occurs in the femur or tibia but can also occur in the elbow or shoulder joints. The radiographic appearance depends on the degree of the bone displacement and the angle of the radiographic projection. When viewed from the side, the fracture appears as triangular fragments of bone at the end of the long bones, often termed metaphyseal chip or corner fractures. When viewed from an angle, the fracture projects a thin shadow of bone elevated above the metaphysis appearing like the handle of a bucket, thus giving rise to the commonly used term bucket-handle fracture.

A young bone that is violently twisted using rotary force, also known as torque, can fracture in a spiral pattern like that found on a cardboard paper towel roll. Skiers, who while stationary, twist and turn despite having one or both feet immobilized by skis, commonly experience rotary force and the resulting injury. The preambulatory infant is unlikely to encounter these kinds of forces unintentionally (Figure 1-19).

Rib fractures in young infants are seen so rarely that they are also considered highly suspicious of physical abuse. The features of the ribcage in a child are such that the ribs will bend and not break, except under the most severe stress. Studies that have attempted to attribute rib fractures to cardiopulmonary resuscitation (CPR) or high falls have been largely unsuccessful,⁵⁴ though shaking with concomitant anterior-posterior compression of the chest wall is thought to be related to abusive rib fractures. The fractures resulting from shaking occur posteriorly at the costovertebral junction and are located more laterally. In general, rib injuries resulting from abuse involve multiple instances of fracture, are located bilaterally, and are found incidentally via chest radiograph or skeletal survey. Abusive injuries of this nature may be detected as acute fractures or as healing fractures with callus formation (Figure 1-20).

Figure1-19

Figure 1-19. This child has multiple rib fractures, as depicted by the arrows. Also note the broken clavicle on the left.

Figure1-20

Figure 1-20. X-rays of the elbow in a young child who reportedly fell off his bicycle the same morning; shows vigorous callus formation (arrows) which is not consistent with a recent injury.

Shaking can also lead to vertebral fractures at the craniocervical junction or at the lower thoracic or lumbar spine due to hyperflexion. Scapular fractures, sternal fractures, and spinous process fractures are highly suggestive of abuse and do not occur without a significant history of trauma. Clavicle fractures without evidence of callus formation, an indication of some healing process, detected in infants older than 10 days of age are suggestive of abuse, as are supracondylar fractures in children younger than 3 years of age and complex skull fractures at any age.

Multiple fractures in the same child are always a cause for concern.⁵⁵ Children who tend to be highly active, are more prone to risk-taking ventures, and have brittle bones do exist; however, with extremely few exceptions, children do not have weak or easily broken bones. Bone diseases and conditions that predispose children to broken and fractured bones are extremely rare and can most often be easily ruled out with a detailed family history, radiologic evaluation of the bones, or a few blood tests. Explanations of frequent fractures resulting from minor falls and attributed to brittle bones should be seriously questioned.

Broken bones not only occur in predictable fashions but also heal over a predictable time period with certain radiologic findings. Serial radiographs of healing bones have provided a great deal of information regarding changes in bones during the healing process. Healing begins immediately after fracture occurs, as evidenced in early radiologic findings, by the formation of a bony callus over the area of disruption. This callus becomes visible on a radiograph between 7 and 10 days after the injury and helps to date the time of the fracture. Experienced radiologists can provide estimates of the age of the injury based on the location and type of fracture, the amount of callus, and the age and general health of the child. Valid explanations for injuries should be consistent with these estimates of age. A history of a very recent fall would be inconsistent with the finding of a fracture with associated callus formation and suggests a delay in seeking medical care. Multiple fractures in different stages of healing are highly indicative of abuse.

Interventions

For