Signs and symptoms of possible child abuse
Signs and symptoms of possible child abuse
A symptom is something you complain of if you are unwell or injured. For example, a child who has been abused may complain of pain, soreness, bleeding or a discharge. The child may be irritable or vomiting.
A sign is an altered state of the body that you can actually see when the child or young person is examined, for example a bruise, an altered shape of a limb because of a fracture or redness and blistering due to a burn.
Symptoms and signs in child abuse have to be taken in the context of the medical and social history (the story) and the developmental status of the child. For example, how does one explain a fractured femur in a child who is not yet walking?
Possible indicators of possible abuse in a child or young person include:
Inconsistency between the story given and the injuries that you see
A story which changes according to who tells it
Frequent attendances in Emergency Departments
Bruising or fracture in a child under the age of one year.
It may be important to include child abuse as part of the differential diagnosis (list of possible diagnoses) for a number of presentations in children, including bruising, fractures, irritability, vomiting etc. The reasons for including possible child abuse in the differential diagnosis should always be documented carefully with the evidence, likewise, any reasons for considering that symptoms or signs are not due to abuse should also be carefully reported if necessary.
It is worth emphasising that the story given must be drawn from as many sources as possible and if an allegation of child abuse is being investigated jointly by Police and Social Services, it is very important indeed that medical/nursing staff hear the accounts given by other agencies.
Physical abuse describes physical injuries to a child as a result of acts of commission or omission. This includes anything from a hand slap to death by suffocation. Injuries may be caused by blows, punches, kicks, shakes, bites, belts, scalds, burns, suffocation, drowning or poisoning.
The injuries may be:
Soft tissue is, bruising, laceration, burns and scalds.
Bony i.e., fracture
Intra-cerebral (brain) injury
Intra-abdominal and mouth injuries
Note - illness fabricated or induced by carers is usually classified with physical abuse.
What do we know about bruising?
Bruising is strongly related to mobility.
Once children are mobile they sustain bruises from everyday activities and accidents.
Bruising in a baby who is not yet crawling, and therefore has no independent mobility, is very unusual.
Only one in five infants who is starting to walk by holding on to the furniture has bruises.
Most children who are able to walk independently have bruises.
Bruises usually happen when children fall over or bump into objects in their way.
Children have more bruises during the summer months.
Where would you expect to see bruising from an accidental injury?
The shins and the knees are the most likely places where children who are walking, or starting to walk, get bruised.
Most accidental bruises are seen over bony parts of the body, for example, knees and elbows, and are often seen on the front of the body.
Infants who are pulling to stand may bump and bruise their heads, usually the forehead.
Fractures are not always accompanied by bruises.
When should you be concerned?
There are some patterns of bruising that may mean physical abuse has taken place.
Abusive bruises often occur on soft parts of the body, for example cheeks, abdomen, back and buttocks.
The head is by far the commonest site of bruising in child abuse.
Clusters of bruises are a common feature in abused children. These are often on the upper arm, outside of the thigh, or on the body.
As a result of defending themselves, abused children may have bruising on the forearm, face, ears, abdomen, hip, upper arm, back of the leg, hands or feet.
Abusive bruises can often carry the imprint of the implement used or the hand.
Non-accidental head injury or fractures can occur without bruising.
Can you age a bruise accurately?
The answer is no.
Estimates of the age of a bruise are currently based on an assessment of the colour of the bruise with the naked eye. The accuracy of observers who estimate the age of a bruise visually is no better than 50 per cent. The evidence is that we cannot accurately age a bruise from an assessment of colour - from either a clinical assessment or a photograph. A practitioner who offers a definitive estimate of the age of a bruise in a child by assessment with the naked eye is doing so from their own experience without adequate published evidence.
Implications for practice
A bruise should never be interpreted in isolation and must always be assessed in the context of the child's medical and social history, developmental stage and explanation given. Any child who has unexplained signs of pain or illness should be seen promptly by a doctor. Unless you are a doctor do not try to make a diagnosis, just describe what you see, mistakes can occur when birthmarks are mistaken for bruises.
Bruising that suggests the possibility of physical child abuse includes:
Bruising in children who are not independently mobile
Bruising in babies
Bruises that are seen away from bony prominences
Bruises to the face, back, abdomen, arms, buttocks, ears and hands
Multiple bruises in clusters
Multiple bruises of uniform shape
Bruises that carry an imprint of an implement or cord.
This information is based on a systematic review of all the quality work in the world literature about bruising on children. Bruising is the most common injury to a child who has been physically abused. These key messages should help you to know when to be concerned about bruising on children.
Pictures of Bruising
These pictures can be distressing. Hit the pop up message below to view.
A fracture in a child or young person should always be assessed in light of the full history, physical findings, x-ray appearances, special investigations and the developmental stage of the child.
What fractures are indicative of abuse?
85% of accidental fractures occurred over 5 years of age.
80% of abusive fractures occurred under 18 months of age.
25% of all fractures under one year were due to abuse.
Highest incidence of abusive fractures was in children under 4 months old.
Abusive fractures are more common in children less than one year of age than those older than 2 years.
Abused children are more likely to have multiple fractures than non-abused children.
Femoral (thigh bone) Fractures
Abusive femoral fractures occur predominantly in infants.
Significantly more abusive femoral fracture arise in children who are not yet walking.
Abusive and non-abusive skull fractures are commoner in young infants.
Overall probability that a skull fracture is due to abuse is 23% rising to 37% if complex.
Linear fractures are the commonest abuse and non-abusive skull fractures.
Multiple or bilateral fractures or those that cross suture lines were more common in abused children.
These are small chip or crack fractures that occur at the ends or growing points of long bones. They are usually due to twisting or gripping injuries.
Metaphyseal fractures are more commonly described in physical child abuse than in non-abuse.
Classical metaphyseal lesions will only be found if rigorous radiological techniques are applied.
Metaphyseal fractures are one of the commonest fractures in fatal child abuse.
Remember that birth trauma can cause metaphyseal fractures in breech deliveries. There are also reports of metaphyseal fractures in inappropriately administered physiotherapy particularly to pre-term infants.
Vertebral, pelvic, hands, feet and sternal fractures (breast bone) occur in physical abuse, appropriate radiology is required for detection.
It is important not to mis-diagnose some common fractures, for example an undisplaced spiral fracture of the tibia (lower leg bone) without an associated fracture of the fibula is most likely to be due to a "toddler fracture" particularly if the child is a boy less than 2½ years.
Implication for Practice
Fractures in children less than 18 months of age should be assessed for possible child abuse.
Multiple fractures are more suspicious of abuse.
The following features may suggest abuse:
Uncommon sites and appearances of burns inconsistent with the explanation or with the development/ability of the child
Round red burns on soft, tender, non protruding parts of the body such as inside of mouth, inside of legs, behind knees, inside of arms or on genitals
Child Sexual Abuse
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (eg. rape or buggery) or non-penetrative acts. They may include involving children in looking at, or in the production of, pornographic material, or encouraging children to behave in sexually inappropriate ways.
Contact may involve:
- Touching, oral contact of breasts, genitalia or anus, masturbation.
- Inserting digits or objects into vulva and anus.
- Rape with attempted/achieved penetration of vagina or anus.
- Oral penetration.
- Erotic talk.
Physical injury may be part of the sexual assault, eg bites on the breasts or sadistic burns on areas as seen in non-sexual assault.
Children of all ages are abused, including infants under a year old, and it is quite common to find that all the children in the family have been abused.
Sexual abuse is damaging to the child, with effects which can be long-lasting on behaviour, emotional state and social relationships. The abuser threatens and demands secrecy. The children feel helpless and may even feel responsible for the badness.
The families with abused children are described as less cohesive, more disorganised and more dysfunctional than those of non-abused children.
The abuse comes to light if the children disclose either on their own or if other suspect because of something seen or behavioural clues.
Older children understand that disclosure may destroy the family, so continued silence and guilt can seem a logical outcome. After disclosure, there is sometimes such pressure from the family that the child retracts, but usually disclosure begins the long process of treatment of the child, the family; and perhaps also the abuser, who may move gradually from denial to acceptance of responsibility.
The examination of the sexually abused child includes:
Sympathetic approach, gender choice of examiner, the child's right to refuse
Therapeutic aspect of the examination, especially if no abnormalities found, part of the healing process
May need to carry out examination in a forensically secure environment
Need to construct a differential diagnosis to explain findings with evidence for each possible diagnosis
A full paediatric assessment including stage of puberty
Signs of physical abuse
The ano-genital area
Signs of sexual assault detected as part of a forensic examination
Infection, arrange appropriate investigations
Follow-up to see healing and to arrange psychological treatment for possible stress related symptoms
The Child Sexual Abuse Jigsaw
History from carer
History from child
Any disclosure, ideally spontaneous
Bruises, other injuries
Sexually transmitted infection
Social Services assessment
Physical signs of Child Sexual Abuse
Symptoms eg, sore bottom
Signs eg vaginal bleeding or discharge
Behaviours eg sexualised
Psychological symptoms eg anger, depression.
Expert medical opinion vital as some suspicious signs may be caused by poor hygiene or by skin diseases
Physical signs of Child Sexual Abuse
There are no signs of recent assault in about 50% of referrals
Reddening which is non-specific
Vulvo-vaginitis - check for STD
Acute signs are tears in hymen, vagina, oedema, erythema, bleeding
Attenuation of hymen (thinning)
Hymenal opening gaping and wide
Healed tears may heal as notch, significance greatest if posterior
Foreign body. (Rare - usually indicates CSA)
Scars are rare
Signs of physical assault - see associated non-sexual injuries
Thick, long posterior labial fusion
Bruising of penis or scrotum
Torn frenulum of penis
Ligature, burn, bite, cut to penis
Foreign body (see above)
Acute signs include erythema, anal fissure, gaping anus, haematoma (of anal margin), selling of anal margin, muscosa prolapsing/lax anus.
More chronic signs include un-healed fissure, lax sphincter, reflex anal dilatation.
Non-specific signs such as dilated veins peri-anally, skin tag associated with healed fissure, congenital tag.
Scars are highly significant and a history is needed ? previous trauma.
Funnelled anus (deeply set anus, usually in adolescence)
Foreign body (see above)
STD - care must be taken and appropriate swabs - a local protocol with the Genito-Urinary Department is needed.
Older children may have no signs of anal penetration, especially is a lubricant is used.
Associated Non-Sexual Injuries
One in six sexually abused children has also been physical abused. Any injury may be seen, but patterns particularly associated are:
Grip mark on limbs
Signs of partial strangulation, linear marks round neck
Bruises over lower abdomen
Injuries to penis, perineum, anus, labia.
Accident eg straddle injury, cross-bar
Early onset of puberty (girls) presenting with bleeding
Congenital abnormality eg septate hymen
Infection eg streptococcal
Infestation eg thread worms
Skin disorder eg Lichen sclerosis, eczema
Inflammatory bowel disease, eg Crohns disease
Rectal polyp presenting with bleeding
Severe constipation leading to an acute anal fissure.
Emotional abuse is part of all the other abuses but also occurs without them. Thus, a child witnessing family violence may be physically well cared for but emotionally distraught. Emotional abuse includes discouragement, ridicule, unfairness, hostility, threats and bullying: "You are bad, stupid, useless and I don't love you".
Emotional abuse is endemic in society and may be used by adults as a form of control in institutions, e.g. in schools, hospitals.
Behaviours/symptoms suggestive of emotional abuse
Continuous withholding of approval and affection by parent/carer
Discipline severe and inappropriate, or non-existent, with few
or no boundaries set
Exploitation by parents/carer to fulfil their needs
Fear of new situations
Impaired ability for play and enjoyment
Lack of curiosity and natural exploration, air of detachment
Inappropriate emotional responses to painful situations
Delayed social and language skills
Persistent head banging or rocking in a younger child
Enuresis and encopresis (wetting and soiling)
Low self-esteem, feeling of worthlessness
Social isolation (including from friends)
Behavioural difficulties including aggression, disruptive behaviour
Eating disturbances, poor growth
Family history of domestic violence, mental illness of a carer
or substance misuse
Only happy at school or kept away
Pseudo mature or explicit sexual behaviour
Open masturbation or aggressive sex play with peers
Stomach pains without medical explanation
Self-harm, mutilation, overdose or attempted suicide
Failure to Thrive or Faltering Growth
Medical and Nursing professionals may define Failure to Thrive (FTT) as a faltering growth pattern
Other agencies, e.g. Social services may use the term to embrace thriving in the wider sense - physically, developmentally, emotionally.
Failure to thrive occurs when a child fails to grow at the expected rate due to an inadequate intake of calories. 5% of children under 5 years FTT and the majority of children who FTT have no organic disorder (coeliac disease, cyanotic heart disease etc). This is evident on examination. Investigations are unnecessary apart from a check for anaemia.
FTT may be associated with neglect and emotional deprivation when these are present but many cases are simply due to lack of calories in feeds, for a variety of reasons. Developmentally, the child may be delayed, language and social skills including attention are most affected. The child is found to lack a strong attachment figure.
Management of FTT depends on the severity of the child's condition but the majority are seen by the primary care team (GP, health visitor, community dietician) while only a few need to be referred to the specialist team.
"The child has a right to expect, and the adult caretaker has a duty to provide: food, clothing, shelter, safekeeping, nurture and teaching". Failure to provide these constitutes neglect (Cantwell & Rosenberg 1990). This includes physical and developmental growth as well as educational, medical and social neglect.
Emotional abuse and neglect are pervasive and much goes unrecognised. "Working Together" (2000) defines neglect as "- the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development" (the concept of "significant harm").
The needs of a child include:
Adequate food Medical and dental care
Love and attention Learning opportunities
Shelter and clothing Education
Protection from harm House and safe play areas.
Most damaging to the child is the failure to meet psychological needs or "- a home low in warmth and high in criticism", which may affect children from any strata of society. (Message from Research 1995)
There is a strong link between neglect and:
Parental alcohol or substance misuse
In addition, the neglected child
May fail to grow and develop to his full potential
Is at risk of long-term disability following accidents, respiratory disease
Is at risk of poor mental health
Is more likely to have inter-current infection especially chest infections, ear infections
May have incomplete immunisation.
Signs of possible neglect include:
Dirty, inappropriate clothing, often too large, wellies
Dirty body, smells, nails thick, yellow, dirty
Hair thin, wispy
Height, weight, mid-upper arm or head circumference demonstrate poor growth.
Development is delayed particularly in language and social skills may be below average:
Play is immature and may lack imagination
Expressive language delayed
At school, delayed language affects reading
Hearing may be impaired due to neglect of "glue ear"
May have neglected squints and visual impairments
Behaviour as observed and reported: distractible, short attention span, over friendly, aggressive, withdrawn etc.
In cases of neglect, it is important to compile a diagnostic jigsaw. In reviewing a child, the various parts of the picture, the history, signs, medical investigations and social background are fitted together like a jigsaw, leading to a diagnosis, but this may take time, for example, in assessing growth.
The Jigsaw of Neglect
Denial by carers of problem. Carers may have learning difficulties.
History of child.
Nursery workers report: Poor care and development. "Attention seeking"
Physical symptoms eg pain from dental caries
Poor physical care
Slow development: language, social skills
Poor compliance with treatment eg, asthma
Increased accidents: fire, drowning, road traffic accident
Poor supportive network: extended family, few strengths
Poverty, poor housing, diet, health
Numerous professional care workers (working effectively?)
The effects on children of neglect and social deprivation after Skuse (1993):
No peer friends
Stealing, lying, self-harm
Produced by members of a South West Local Safeguarding Children's Board