++
Like other forms of family violence, the maltreatment of children
usually occurs in the privacy of a home and is seldom witnessed
by another person. Because the child is often too young or too frightened
to explain what happened and the correct history often is not known
or not provided by the parents, clinicians should be aware of suspicious
histories and recognize the typical behaviors and physical findings
of maltreated children. Although 3 types of maltreatment (physical
abuse, neglect, and sexual abuse) are described separately, a child
may suffer from more than 1 type.
++
Five types of histories should raise the suspicion of abuse:
(1) a child with a serious injury, such as a fracture, but no history
of preceding trauma (eg, “I noted that his arm was limp”); (2)
a history that is inconsistent with the severity, mechanism, or
timing of the injury; (3) a delay in seeking medical care for a
significant injury; (4) a history that changes during the course
of the evaluation; and (5) a history of recurrent injuries, especially
those that are poorly explained.
++
Children who have been abused display a variety of behaviors.
They may be excessively fussy, frightened, or depressed due to recurrent pain,
maltreatment, and the impact of living in a threatening and unpredictable
environment. Older children may demonstrate role reversal in their
interactions with their parents: Instead of the parent caring for
the child’s needs, the children learn to be particularly
sensitive to the parents’ needs and, in part, to avoid
being hurt, may provide care for the parents. Such children may
attempt to be well behaved around adults in order to avoid offending
them and being punished. Some children who have been abused repeatedly
do not cry during medical procedures, such as blood drawing, because crying
at home may have resulted in additional punishment.
++
The spectrum of physical abuse extends from a single episode,
such as a slap on the face, to recurrent and more serious injuries. Children
who sustain injuries from abuse that are mistakenly diagnosed as
unintentional injuries are at substantial risk of being more seriously
hurt or even of dying from abuse. Soft tissue injuries are the most
common clinical manifestation of physical abuse. These include hand
marks from slapping; bruises from punches; linear and curved marks
from belts, cords, or switches; and bite marks. In evaluating injuries
to the skin, it is important to consider the child’s developmental
level. For example, 1 year olds who are learning to walk often fall
forward and bruise their face, and it is not uncommon for preschool
children to bruise their shins. Studies of bruises in young children
have demonstrated that it is unusual to see bruises in children
who are not cruising.28 “Black eyes” and
bruises around the ears, in the genital region, or on the posterior surface
of the body are highly suspicious of abuse at any age. Bruises result
from bleeding into the skin or subcutaneous tissues. Fresh bruises
are usually tender and swollen, with maximum swelling in 1 or 2
days. Bruises change color from deep purple/red to green
to yellow/brown. The rate of these changes depends on the
depth of the bruise, the amount of bleeding, the location of the
injury, possible drugs the child has taken, or the inherent clotting
ability of the child. Because of the many factors involved in bruise
progression, dating an injury based on the appearance of a bruise is
inexact.29
++
Burns are another common type of abusive injury. These can include
scald burns from hot liquids or burns from hot objects, such as
irons, stoves, or cigarettes. Although burns that are due to abuse
are often difficult to distinguish from unintentional injuries or
those due to neglect, the location and pattern can be helpful. Children
who have been immersed in hot water may have bilateral burns of
the upper or lower extremities or burns of the buttock or back. These
inflicted burns often have a sharp demarcation between the injured
and noninjured skin. A child who has been held in hot water in a
tub may have a spared area of buttocks, as a result of the area
having been pressed against the tub. In contrast, nonabusive scalds
tend to be asymmetric from one extremity to the other, have less
sharply demarcated borders, and reveal splash marks that indicate
the child tried to avoid the injury.30 Other commonly
occurring unintentional scald burns occur when young children spill
containers of hot liquid on themselves.
++
Cigarette burns are another type of suspicious injury. An isolated,
unintentional cigarette burn, which tends to be superficial, can occur
when a young child comes in contact with a cigarette held by an
adult. In contrast, inflicted cigarette burns tend to be deeper,
are located on areas to which accidental contact would be unlikely,
and may be multiple.
++
Head injuries are the most common cause of death due to child
abuse. A recent epidemiologic study found the incidence of abusive head
trauma to be 32.2 per 100,000 infants between 0 and 12 months old.31 Abuse
can occur from shaking alone or from a combination of shaking and
blunt impact. An analysis of perpetrator admissions of abusive head
trauma indicates that shaking is the most common mechanism of abusive
head trauma.32 Because in most cases the actual
mechanism of injury is not observed, the use of a general term such as abusive
head trauma is preferable to a specific term like shaken
baby syndrome, which implies a single mechanism of injury.
An important secondary mechanism involved in abusive head trauma
is hypoxic ischemic injury that occurs as a result of the initial
trauma.33,34 Abusive head trauma can result in intracranial
bleeding due to repeated accelerations and decelerations of the
brain that produce shearing of the bridging veins (resulting in
subdural or subarachnoid hemorrhages) and retinal hemorrhages, which
often can be extensive, involve different layers of the retina, and
extend to the periphery (see Chapter 587).35,36
++
Children with abusive head injuries may present with seizures,
signs of increased intracranial pressure, coma, or apnea and cardiac
arrest. Often, there are other signs of child abuse, such as bruises
or healing fractures. Rib fractures can be seen in conjunction with
abusive head trauma; these fractures occur when the infant is held
around the thorax, and the abuser squeezes the chest causing anteroposterior
compression and posterior rotation.37 Because rib
fractures are usually not visible on chest radiographs until callus
formation has begun to occur 10 to 14 days after an injury, the
presence of an acute head injury and healing rib fractures indicates
that the child has been injured on at least 2 occasions.
++
In head injuries due to abuse, there usually is no clear history
of severe head trauma to direct the clinician toward the right diagnosis.
In contrast, when children sustain serious unintentional intracranial
injuries, such as those due to major falls or automobile accidents, there
is a clear history to explain the injury, and retinal hemorrhages
occur much less commonly. Most minor falls from heights of less than
36 inches do not result in serious head injuries, although skull
fractures, with and without small, transient, and localized areas
of subdural bleeding near the fractures, as well as epidural bleeding,
can occur. Scalp hematomas are more common in children who sustain accidental
falls than in children with abusive head injuries.36
++
Fractures of bones are another common type of abusive injury
in young children. In a series of 215 children under 3 years of
age with fractures, 24% were believed to be due to abuse.38 The
highest occurrence of abusive fractures is in children under 1 year
of age. Skull fractures that are depressed, branching, or diastatic
have been associated with physical abuse; the most common type of
skull fracture, however, found as a result of abuse (as well as
with unintentional injuries) is a linear fracture of the parietal
bone.38,39 Fractures of the humerus (especially
midshaft or proximal) and fractures of the femur (especially in
children under 1 year of age) should be considered suspicious of abuse.
In contrast, a 2- or 3-year-old child may have a supracondylar fracture
of the humerus from a fall on an outstretched arm or a spiral fracture
of the femur or tibia from falling and twisting. Whether the fracture
is spiral or transverse is not by itself diagnostic for abuse. Rather,
a careful consideration of the nature and severity of the injury,
the proposed mechanism of injury, and the developmental abilities
of the child should be undertaken.40 Two types
of fractures more specific for abuse are classic metaphyseal, or
bucket handle, fractures and rib fractures, particularly those that
are posterior and adjacent to the spine. Several studies have indicated
that rib fractures are unlikely to occur during cardiopulmonary
resuscitation in young children.41
++
Other types of injuries that should raise the suspicion of abuse
are intentional poisonings and abdominal injuries (including lacerations of
the liver, spleen, or intestines). Children with abdominal injuries
are at particular risk of hypovolemic shock and even death when the
internal injury is unrecognized and the history of blunt trauma
is not provided by the caregiver. Multiple abdominal injuries, a
high severity of injury, and a delay in seeking care should prompt
particular concern for abuse.42
++
An additional form of abuse that is often difficult to recognize
is medical child abuse, in which a parent (usually the mother) fabricates symptoms
of an illness in the child resulting in an extensive medical evaluation,
or causes the child to be ill by poisoning or some other means (eg,
injecting contaminated fluid into an intravenous line) in order
to assume the sick role by proxy. Caregivers who perpetrate medical
child abuse for the gratification of having a sick child are given
a psychiatric diagnosis of Munchausen syndrome by proxy (MSBP),
or factitious disorder by proxy. Medical child
abuse has a high fatality rate because diagnostic efforts are focused
on the sick child, and MSBP is often recognized too late in the
caregiver. The most common presentations of medical child abuse are
seizures, apnea, diarrhea, and fever.43,44 Studies
of MSBP have focused on 2 other conditions—apparent life
threatening event and multiple sudden infant death syndromes in
families—that can be caused by abusive behaviors, such
as suffocation or strangulation. In a British study of 39 children
(age range of 2–44 months) who were referred because of
suspicion of an induced illness, 36 presented with apparent life-threatening
event. In the 39 families, 12 previous children had died suddenly
and were labeled as deaths due to sudden infant death syndrome. Covert
video recordings in the hospital revealed abuse in 33 cases, and
there was documentation of suffocation in 30 of these children.
In 11 of the cases of suffocation, the children had bleeding from
the nose and/or mouth.45 When more than
1 infant in a family dies unexpectedly and is labeled sudden infant
death syndrome, child abuse and other causes, such as metabolic
ones, need to be considered. Educational disabilities, behavioral
problems, and psychiatric disorders have also been fabricated by
parents who were ultimately diagnosed with MSBP.46,47
++
Neglected children are recognizable by the chronic failure of
their parents to provide adequate physical care or ensure appropriate
medical care or education, or when the child is brought for medical
attention because of an injury or ingestion due to failure of adequate
supervision. Worrisome histories include evidence of inadequate
provision for the child’s basic needs, inadequate supervision,
or a delay in seeking medical care. It should be noted, however,
that neglect in its less obvious forms can be quite difficult to
define.48
++
In infants and young children, a common manifestation of neglect
is poor growth and developmental delay due to decreased nutritional
intake and understimulation. Such children, who are labeled as having
nonorganic failure to thrive, often are recognized first because
of poor weight gain or because they fall off the growth curve. Initially,
the child’s length and head circumference may be relatively
spared, but if the nutritional deprivation continues, these parameters
also are affected. The general pattern of growth for decreased nutritional
intake, regardless of the cause, is for weight to be most affected
and head circumference least affected; this pattern can be ascertained
by plotting each of the growth parameters on the 50th percentile
curve and determining the child’s age at the respective points
(eg, the child’s “weight age”). In many children
whose failure to thrive is due to neglect, there also is a developmental
delay, particularly affecting the child’s language and social
interactions. Such children may appear listless, have a flat affect,
and demonstrate indiscriminate attachment behaviors. Older children
who are neglected often appear as emotionally needy. They may be
depressed or adultlike in their behaviors as a result of having
to learn to care for themselves. Acute problems, such as ingestions,
burns, or injuries from falls, are common presentations in neglected
children and should be distinguished from abuse or unintentional
injuries.
++
Children who have been sexually abused generally come to the
attention of clinicians because the child has told an adult about
an uncomfortable experience (eg, “My uncle touches me down
there, and I don’t like it”), the parent becomes
concerned about the child’s behaviors (eg, sexualized acting
out) or symptoms (eg, vaginal discharge), or a genital or anal abnormality
is noted on physical examination.
++
Although the child’s statement is one of the clearest
indications that the child has been sexually abused, a very young
child may have difficulty explaining what happened, and an older
child may retract a relatively clear statement after the child begins
to understand how upsetting the disclosure is to the family. In certain
circumstances, such as disputes about custody or visitation, it
may be particularly difficult to determine the truthfulness of the child’s
statements because of the complexities of the relationships in the
family.
++
Children who have been sexually abused may demonstrate a variety
of behaviors and symptoms. Many are nonspecific and are seen in
response to other childhood stresses as well, such as poor school
performance, generalized anxiety, encopresis, or suicidal gestures.
Others are more suggestive, but not specific, such as excessive
masturbation, sexualized behaviors, vaginal discharge or bleeding,
or rectal bleeding. Even a symptom such as vaginal discharge, however,
has a low likelihood of being due to sexual abuse. In several studies
of premenarcheal girls with the complaint of vaginal discharge,
the most frequent diagnosis was poor hygiene, and sexual abuse was
found in less than 5% of cases.49
++
Although all children suspected of being sexually abused should
have a complete physical examination, most are likely to have normal
findings on examination. In a study of 2384 children referred for
possible sexual abuse to a tertiary referral center, the investigators
found that only 4% of the children had an abnormal genital
or anal examination at the time of evaluation.50 A
normal examination does not rule out sexual abuse, as there may have
been no injury to the genital area or, if there was an injury, it
might have healed without leaving any signs. In cases in which there has
been a conviction of a perpetrator, it is unusual for victims to
have an abnormal physical finding. In a series of 236 children where
the perpetrators were convicted, 23% of genital examinations
of girls and 7% of anal examinations of all children were
considered abnormal or suspicious.51 In a study
of 36 adolescent girls who became pregnant as a result of suspected
sexual abuse, only 2 of the 36 girls had definitive genital findings
of penetration.52
++
Considerable research in the last several years has been conducted
to define normal and abnormal genital and anal anatomy in prepubertal
children. The appearance of the hymen is often thickened in early
childhood because of the effects of maternal estrogen in utero;
in preschool and school-age girls, the hymenal tissue becomes thinner
until the effects of estrogen during puberty result in a thickening
of the tissue and the development of redundant folds. Studies of
normal prepubertal girls have described the shapes of the hymen
as crescentic, annular, and fimbriated (or redundant) and have noted
the frequency of normal variations, including hymenal mounds, intravaginal
ridges, and adhesions of the labia minora.53,54
++
Lacerations or bruising of the hymen, perianal lacerations extending
deep to the external anal sphincter, healed hymenal transections, and
a missing segment of hymenal tissue are findings with a high specificity
for penetrating trauma. Transections and missing segments of hymenal
tissue should persist when the child is examined in the prone, knee-chest
position. Scarring, such as of the posterior fourchette or perianal
area, may be indicative of previous trauma.55
++
Anal findings, such as acute fissures, also can be seen in sexually
abused children. Normal findings in the prone, knee-chest position include
skin tags in the midline, fan-shaped areas in the midline superiorly,
perianal erythema, venous congestion, and anal dilation up to 2
cm.56 Children who sustain anal trauma as a result
of sexual abuse may not have abnormalities on examination if the
event is not acute. In a study of children with documented anal injuries
followed from acute injury to healing, 29 of 31 children healed
completely, with scar formation in only the 2 cases requiring acute surgical
repair.57
++
Children who have been sexually abused may acquire a sexually
transmitted infection, and adolescents are at risk of becoming pregnant.
The most common infections are gonorrhea and chlamydia. Also, there
have been several reports of human immunodeficiency virus (HIV)
infection that were transmitted by sexual abuse. The confirmed infection
of a prepubertal child with gonorrhea, syphilis, or chlamydia, if
not perinatally acquired is thought to be diagnostic of sexual abuse
and must be reported. Rarely, gonnorhea can be transmitted in a
nonsexual manner. Similarly, the presence of HIV infection in a
prepubertal child, if not perinatally or transfusion acquired, is
diagnostic of sexual abuse and must be reported.58 Human
papillomavirus (HPV) presents a special case in the evaluation for possible
sexual abuse. Although previously believed to be to the result of
perinatal transmission, HPV is either rarely vertically transmitted or
never vertically transmitted.59,60 Recent epidemiologic
data suggest that many preadolescent children acquire HPV from nonsexual horizontal
transmission, either by autoinoculation if a child has common skin
warts or horizontally from nonabusive contact by a person who has
common warts, and that the likelihood of sexual abuse as a possible
cause increases with age.61,62 History and full
medical evaluation are of particular importance in ascertaining the
possibility of sexual abuse in a child with HPV.