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 [email protected])
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