Physical Abuse of Children

by

Jim Carpenter MD,MPH,FAAP

October 21, 2009

Objectives1.Develop a schema to identify the

signs and symptoms of Child Physical Abuse(CPA)

2. Report reasonable suspicion of physical abuse to the appropriate agencies

Missed DiagnosesFamily Violence including child abuse,

elder abuse and domestic violenceMental health conditions including

depression and anxiety disordersSubstance use and abuse

Definitions of Child AbusePhysical injury inflicted intentionally

upon a childNeglect: “general” or “severe”Sexual abuse including molest, assault

and exploitationEmotional abuse including willful

cruelty, unjustified punishment and mental suffering

Prevalence Second to neglect in reported cases of child

maltreatment accounting for 18-20%. 26.4% of an adult cohort reported CPA. 1.3-15% of ED visits for child injury. Underreported and misdiagnosed

31% of children with AHT were initially misdiagnosed

Due to lack of training, reluctance to report, failure to consult, and low index of suspicion

Fiscal Year 2006

3.3 million referrals to child protective services.

62% were screened in for investigation.30% of reports found at least 1 child who was

a victim.60% of reports were not substantiated.

Who Reported?

56% of all reports were made by professionals. Teachers: 16.5%. Police, lawyers: 15.8%. Social services: 10%. Medical, mental health professionals: 12%. Other professionals: 2% 2/3 of substantiated reports were made by

professionals.

Who Were the Victims?905,000 total Birth to age 1 years: 24.4/1,000Younger than 7 years: 55%Race

White: 49% African American: 23% Hispanic: 18% Other, unclassified: 10%

Types of Maltreatment

64%: Neglect16%: Physical abuse9%: Sexual abuse7%: Emotional maltreatment

Child Abuse Fatalities 1,530 died. Rate of death: 2.04 children per 100,000. 42% of deaths caused by neglect. 27% caused by combinations of maltreatment. 24% caused by physical abuse. 2.5% caused by medical neglect. 76% of deaths occurred in children younger than 4

years.

Perpetrators

79% were parents.7% were other relatives.Unrelated caregivers: 10%.Women: 58%.

Sequelae of Physical Abuse Mortality and Morbidity from the injury. Behavioral and Functional problems

including conduct disorder, aggression, school problems and failure, anxiety and depression, low self esteem, PTSD, criminality.

Subsequent generations of family violence. ACE(Adverse Childhood Experiences)

sequelae

ACE and Chronic Disease ACE including all forms of child maltreatment

increase the risk for: Diabetes and Obesity Hypertension Depression Substance Abuse Ischemic Heart Disease Risk taking behaviors ie. STI’s Chronic Lung Disease

Risk Factors for Abuse Age less than 2-3 years Poverty Single, isolated parent Unrelated adult in home Low birth weight Substance use/abuse Developmental delays in child Family history of DV or child maltreatment

Medical History Concerning for Intentional Trauma

No or vague explanation for injury.Details of injury change.Explanation that is inconsistent with the

injury.Explanation is inconsistent with child’s

physical or developmental abilities.Different explanations by witnesses.Delay in seeking care

Past Medical HistoryPregnancy(prenatal care, planned,

substance use, depression, support)Family Hx(bleeding, metabolic or

genetic disorders, violence, depression, substance use)

Medical(trauma, chronic illness, FTT,shot delay, developmental delays)

Social(poverty, stressors, support)

Physical ExaminationABC’s and VS including Ht, Wt and HCEarly Neurologic assessmentSkin(bruises, abrasions, patterned

marks, burns, SQ fat, hygiene)HEENT(swelling, contusions, alopecia,

full fontanelle, hemotympanum, black eyes, slap or choke marks)

Cutaneous Injuries

Key characteristicsLocationPatternMultiple ages of lesionsFailure of appearance of new lesions in

new environment

Incidence and Prevalence 50% to 60% of all physical abuse cases have

skin injuries, in isolation or in combination with other abusive injuries.*

Cutaneous injuries are the single most common presentation of physical abuse.

*Johnson CF. Pediatr Clin North Am. 1990;37:791–814.

ACCIDENTAL ABUSIVE

Shins Upper arms

Lower arms Anterior thigh

Under chin Trunk

Forehead Genitalia

Hips Buttocks

Elbows Face

Ankles Ears

Bony prominences Neck

Usual Locations of Bruises

Slap Mark in 4-Month-Old Infant

Strangulation Marks on Neck

↑↑

The canine impressions are labeled with red arrows and have a distance of 4 cm between them. The 4 outlines of teeth between the arrows are from the incisors.

Aging of Bruises

Visual aging of bruises is inexact. Bruise with yellow is more than 18 hours

old. Red, blue, purple—present 1 hour to

resolution. Red color can be present anytime. Bruises of same age on same person can

vary in color.

Differential Diagnosis of Bruises

Typical Distribution of Slate-gray Nevi

Phytophotodermatitis

Cao Gio (Coin Rubbing)

Henoch-Schönlein Purpura

Forehead Bump With Migration

Abusive Burns

Bic Cigarette Lighter Burn

Iron Burn—Note Location

Immersion Burn

Differential Diagnosis of Burns

Second degreeBullous impetigoStaphylococcal scalded skin syndrome

(SSSS)Toxic epidermal necrolysisEpidermolysis bullosa

Staphylococcal Infection

Contact Dermatitis—Ex-Lax

Moxibustion

Abusive Head Trauma Leading cause of CPA death and significant

morbidity(blindness, CP, ADHD, retardation, seizures).

Survey showed 2.6% of mothers shake their children <2 yo for discipline.

Correlates with normal crying behavior. Often is asymptomatic and easily missed by H&P. Prevention works! Anticipatory guidance or Mark

Dias MD Program or Period of Purple Crying Program

Period of PURPLE CryingPeak of crying(second month)UnexpectedResists soothingPain-like faceLong-lasting(30-40 minutes and longer)Evening crying

Suspicious Stories in Fatal Child Abuse Cases (Kirschner)

1. Child fell from low height.2. Child fell onto furniture, floor, or object.3. Child unexpectedly found dead (age and

circumstances not suggesting SIDS).4. Child choked; shaken to dislodge object.5. Child turned blue; shaken to revive.6. Child experienced sudden seizure activity.

Common Suspicious Stories

7. Resuscitation efforts caused injuries.8. Caused by traumatic event a day or

more prior. 9. Adult tripped or slipped while carrying

child.10. Child’s sibling did it.11. Child left alone for short time.12. Child fell down stairs.

Clinical PresentationPoor feeding, vomitingLethargy, irritabilitySeizuresApnea or respiratory distressColor changeUnresponsivenessHypothermia

Parietal Skull Fracture

Retinal HemorrhagesDilated retinal exam by OphthalmologistFound in 80-90% of infants with severe

shaking with or without impact.Can occur from birth but are small and

resolve by 2-4 weeks.R/O vitamin K deficiency or glutaric

aciduria type 1.

Chest Examination Rib fractures(pain, crepitance,

splinting,palpable callus, tachypnea, shallow breathing)

Rib fractures often occur in adults from CPR but rarely in children and almost never in infants.

Heart trauma is rare but if present is severe(hemopericardium and contusions)

Rib FracturesPosterior fractures are most common.Next most common is mid-axillary.Overlying bruises may be seen, but are

often absent.Symptoms are usually absent.Grating feeling may be present.

Abdominal Injuries

Abusive Younger child (2.6 y) Vague histories Delayed medical

care Hollow viscera Mortality rate: 53%

Accidental Older child (7.8 y) 90% credible

accident history (eg, MVC, fall)

Prompt medical care Solid organ Mortality rate: 21%

Signs and Symptoms Abdominal tenderness Abdominal distention Absent bowel sounds Obtundation Low hematocrit Blood in nasogastric drainage, hematuria Bruising of abdominal skin

Extremity ExaminationObserve for deformity, swelling, lack of

use, discoloration, tenderness, ROM.Skeletal survey is indicated in <2 yo

with suspected CPA/neglect.Repeat in 2 weeks in selected cases.R/O rickets, scurvy, syphylis, and

osteogenesis imperfecta(blue sclera, osteopenia,bad teeth, lax ligaments)

When to Suspect Abuse Metaphyseal fractures in children

younger than 2 years Posterior rib fractures Scapular fractures Spine fractures Sternal fractures Multiple, especially bilateral fractures

When to Suspect Abuse Fractures to hands or feet Fractures in infants or young children Fractures in children of poverty Fractures in prematurely born children Fractures in developmentally

handicapped Fractures with unexplained associated

injuries

Diagnostic Testing for CPABleeding screen(CBCD, platelets, INR,

PT/PTT, VWF, Vit K, or other factors).Abdominal screen(LFT’s, amylase,

lipase, urinalysis, CT scan> KUB).Fracture screen(skeletal survey, bone

scan, 2 week f/u survey).Cranial screen(MRI, CT, skull XR, urine

organic acids, retinal exam).

Other Diagnostic TestingCardiac screen(troponin, CK-MB)Osteogenesis imperfecta(FHx, skin bx

for fibroblast culture, blood for DNA).Other bone disorders:ie. rickets(Ca, Alk

P, Phosphorus, Vit. D, PTH, Vit. C, RPR).

Tests to diagnose mimics of CPA.Consider toxicology and forensics.

Diagnostic Studies

Documentation of CPAPhotography is recommended for all

significant injuries.Completion of the CalEMA 2-900 and

SS8572 reporting forms.Completion and review of all other

medical records. Inconsistencies in the record will haunt

you if a case goes to prosecution.

Reporting of CPAMandated reporters are required to

report suspected CPA to CFS/LE by phone as soon as possible and in writing within 36 hours.

Many cases are ambiguous so consult with pediatrician/supervisor to discuss management and need to report.

CalEMA 2-900 Reporting Form

7 pages 5 years in the

making Prompts for Hx, PE,

forensics and diagnostics

ReportingAll states have reporting laws of

suspected child abuse by mandated reporters

Reports go to CPS and/or LE Immediately by phone and in writing

within 36 hoursTo commence investigation, protect the

child, and help the family

Mandated Reporters Nurses Doctors EMT’s Teachers PT OT Firemen

Police Childcare providers Photo processors CPS workers Animal control Clergy Child visitation

monitors

Reasonable Suspicion “It is objectively reasonable for a person

to entertain a suspicion, based on the facts that could cause a reasonable person in a like position, drawing when appropriate, on his or her training and experience, to suspect child abuse and neglect” (PC 11166a1)

Obstacles to ReportingDenialFear of making a mistakeDeferring to another reporter’s lower

index of suspicionFear the report will make things worse

or make no differenceFear of angry parentsFear of court testimony

Penalties for Failure to ReportMisdemeanor punishable by up to 6

months in jail and/or $1000 fine If GBI or death results- up to one year

and/or $5000 fineCivil liabilityPotential loss of credential or license

Safeguards for Reporters Immunity from criminal liability if report

made in good faithSupervisors may not impede or

sanction reportersReports and reporter are confidentialExamination, photography and indicated

tests do not require consent from potentially abusive parent.

Prevention of Child AbuseRecognition and reportingHome visitationParenting educationSubstance abuse identification and

treatmentMental health diagnosis and treatment

Resources for CPA Child and Family Services-(925-646-1680 or

877-881-1116) or CPS Alameda County(510-259-1800)

Jim CrawfordMD/Center for Child Protection(510-428-3742)

Jim CarpenterMD/CCRMC (x210 or drjimcarpenter@yahoo.com)

Child Abuse Prevention Council - (925-798-0546) or www.capc-coco.org.

www.dontshake.org

Bibliography Nursing Approach to the Evaluation of Child

Maltreatment; Giardino & Giardino, 2003 Child Abuse:Medical Diagnosis & Management,

3rd edition: Reece & Christian; AAP; 2009 Visual Diagnosis of Child Abuse,3rd

edition;Lowen & Reece; AAP “The Relationship of Adverse Childhood

Experiences to Adult Health, Well-being, Social Function, and Healthcare”; Felitti and Anda; AAP/San Francisco; 2007

Bibliography- continued “Diagnostic Imaging of Child Abuse”;

AAP Section on Radiology; Peds123:5, pp1430-35; 5/2009

“Abusive Head Trauma in Infants and Children”; Christian and Block; Peds123:5, pp1409-11; 5/2009

“Evaluation of Suspected Child Physical Abuse”; Kellogg; Peds119:6; pp1232-41

Thank You