6 Child Abuse and Neglect
Child abuse and neglect constitute a pediatric public health problem of enormous magnitude. Their relative contribution to morbidity and mortality in children is likewise huge. In addition to the fact that more than 900,000 children are identified as substantiated victims each year, approximately 140,000 incur serious injuries and nearly 20,000 are left with permanent physical disabilities such as cerebral palsy and blindness. The toll on emotional development is even more significant.
The incidence of reported cases of abuse and neglect has increased within much of the twentieth century, in part due to improved identification and reporting. Whereas in the past 20 years there has been a decline in substantiated cases of physical and sexual abuse, there has been no change in mortality rates. Caffey in the late 1940s and then Kempe and coworkers in the early 1960s fostered a marked increase in the recognition of the physical manifestations of abuse and of the very real needs and problems of child abuse victims. Subsequent passage of legislation in all 50 states mandating that suspected cases be reported to the proper authorities has further increased the incidence of reporting. Thus, although some of the increasing incidence is real, much is probably the result of these developments. In addition, societal standards have changed, for some of what is currently regarded as abuse was once sanctioned as discipline.
Four major forms of abuse have been delineated: physical abuse, sexual abuse, physical neglect, and emotional abuse. Not infrequently, an individual child is found to be the victim of more than one form and there is some degree of emotional abuse with all forms. For purposes of reporting under child protection laws, the abuse or neglect generally must result from the acts or omissions of a parent, guardian, custodian, or other caretaker of the child.
Of reported cases about 60% involved neglect, 19% physical abuse, 9% sexual abuse, and 5% were identified as emotionally maltreated. These figures may significantly underestimate the actual number as it is estimated that for every case reported, at least two go unreported. Clearly, some, perhaps many, reports concerning truly abused children are inaccurately determined to be unfounded, sometimes because regulations preclude this if a perpetrator cannot be clearly identified despite the fact that the child has clearly been the victim of abuse. Misleading/deceptive histories, limited investigative resources, lack of witnesses, inability or unwillingness of victims and family members to attest to the fact that abuse has occurred, and jurisdictional regulations all contribute to this phenomenon.
Fatality statistics have also been found to have limited accuracy. The National Child Abuse and Neglect Data System (NCANDS) estimates that there were about 1740 deaths in 2008. This is an increase from approximately 1500 cases in 2003 and is likely due to recent improvements in the reporting and investigation of child fatalities. This in turn probably reflects improved recognition of child abuse–related deaths as a result of the institution of child death review teams in most states. Of fatal victims, 40% to 50% are younger than 1 year of age, and 85% to 90% are 5 years of age or younger. Researchers looking at data from additional sources have determined that many, perhaps the majority, of deaths due to abuse are misclassified as due to accident, sudden infant death syndrome (SIDS), or natural or unknown causes. Reasons for misclassification include incomplete medical evaluation; delay in or inadequate death scene investigation, or no scene investigation; lack of sufficient training of coroners and pathologists regarding child abuse and the techniques and studies necessary to identify abuse at autopsy; failure to require manner of death, as well as cause, on death certificates; and poor communication among investigative agencies. Thus most authorities believe 2000 deaths per year is a more accurate figure, although this, too, may be a significant underestimate. To put this in further perspective, the number of deaths due to abuse of children younger than 5 years is greater than the number due to motor vehicle accidents and fires combined and is more than twice the number of deaths due to accidental choking or suffocation, drowning, and falls combined.
The most common causes of death due to abuse are head trauma, abdominal trauma, and suffocation. Of these, intentional suffocation is most likely to go undetected, as autopsy findings may simulate SIDS. It now appears that a large percentage of cases of SIDS are actually due to accidental suffocation as a result of sleeping prone on a soft surface, of getting the face covered in bed clothing, or of co-sleeping with one or more adults whether in bed or on a sofa or easy chair. The Back to Sleep campaign, begun by the National Institute of Child Health and Human Development, and efforts to educate parents about the risks of co-sleeping have dramatically reduced the incidence of these tragic deaths. Further review of co-sleeping deaths points to a disturbing number of cases in which the adult sleeping with the child has a history of substance misuse.
All sudden unexpected deaths in infancy warrant thorough investigation to facilitate accurate determination of cause, assess for possible foul play, and aid in future prevention. Certain historical points and physical findings may aid in distinguishing SIDS from intentional suffocation. Infants dying of SIDS are usually younger than 6 months of age, previously well (or have only mild symptoms of an upper respiratory infection), and found unresponsive in the early morning when their parents awaken. In contrast, those dying of intentional suffocation may range from weeks to 2 or 3 years of age and are more likely to be “found” sometime between mid-morning and late afternoon or evening, after a period of being with a single caretaker. In some, subtle bruises or petechiae of the face and/or neck or scant bleeding from the nose or mouth may be noted. Many of these infants have a history of a recent hospitalization for an unexplained illness or for apnea, seizure-like activity, or an apparent life-threatening event (ALTE), for which no cause could be found despite an extensive medical workup. This or a past history of multiple apparent life-threatening events and/or a history of two or more prior sibling deaths attributed to SIDS should raise strong suspicion of intentional smothering.
Epidemiology
Child abuse is a phenomenon found in all socioeconomic, cultural, racial, ethnic, and religious subsets of society. The reported incidence per capita is greatest in lower socio-economic groups. This stems in part from the numerous chronic stresses and uncertainties of living in poverty, problems of socialization, and different attitudes regarding what constitutes appropriate discipline. It is also clear, and must be recognized by physicians and other professionals, that well-educated parents of higher socioeconomic status can be abusive; however, when they are, they are less likely to be suspected. This is in part because they “come across well” as they tend to be well dressed, well spoken, more sophisticated, and have a more confident demeanor than parents who are less well off. Also, they are often better able to fabricate a plausible history of how the injury occurred “accidentally.” Furthermore, when suspected, they are less likely to be reported, and when reported, they are more likely to have the resources and legal assistance to have the case dropped or dismissed, or to be acquitted of the charges. Hence in evaluating potential abuse victims and their families, it is important not to rush to judgment of parents on the basis of appearance, dress, and level of sophistication, and professionals should appreciate that many parents who are poor, unsophisticated, and not well dressed are loving and caring despite their limited means and resources.
The most valuable information is gained by a nonjudg-mental approach while keeping an open mind in obtaining a thorough history, making careful behavioral and interactional observations, performing meticulous examination, and ordering a well-considered laboratory and imaging evaluation before arriving at a diagnosis.
Parental Risk Factors for Child Abuse and Neglect
1 Past history of being abused or neglected as a child. Although this is a significant risk factor, it is important to note that not all abused children grow up to become abusive adults. Those who do not have been found to have had a strong, long-standing, and supportive relationship, from early childhood, with a nurturing and nonabusive adult who loved them unconditionally, helped them recognize their own worth, and taught them how to make good choices. This enables them to develop trusting relationships and, hence, better social support systems.
2 Poor socialization and emotional and social isolation. Inadequately nurtured themselves as children, these parents are poorly equipped to adequately nurture their offspring. Their own mothers may not have bonded well with them, and/or their trust may have been betrayed repeatedly by those they loved unconditionally and should have been able to count on most. They may have been shuttled back and forth between the parental home and relatives’ or foster homes or placed in a series of foster homes over the course of years. As a result, they have trouble with trust and forming close attachments, and hence, are poorly equipped to develop and use support systems. They tend to have little understanding of child development and of children’s emotional and other needs and, therefore, of good child-rearing practices and reasonable expectations of child behavior. E-Tables 6-1 and 6-2 present common features of many of the families of origin of abusive parents/caretakers, as well as their child-rearing practices, which then tend to be repeated by these younger parents and by ensuing generations. E-Table 6-3 presents common character traits and historical revelations of many poorly socialized parents/caretakers and of those with character disorders.
3 Limited ability to deal adaptively with stress and negative emotions such as fear, anger, and frustration, compounded by a tendency to lash out violently, verbally and/or physically, in response to negative feelings. This behavior is often learned by example in their families of origin.
4 Alcoholism/substance abuse. When intoxicated or high, such parents may be “out of it” or may be disinhibited in approaching or dealing with their children. They also may be away for extended periods, seeking their substance of choice or the wherewithal to obtain it.
5 Mental illness (e-Table 6-4).
6 Domestic violence in the parental relationship.
7 Being subjected to a sudden spate of major life stresses/crises such as loss of job and financial security; loss of home; loss of parent, spouse, or sibling.
e-Table 6-1 Common Characteristics of the Family of Origin of Poorly Socialized Adults Given in Psychosocial History*
| History | Potential Effect on Children |
|---|---|
| Evidence suggestive of impaired bonding | Failure of bonding in first 6 months results in the following: |
| Maternal depression postpartum | Inability/impaired ability to truly attach, trust, and, ultimately, to nurture |
| Mother chose to go right back to work | Inability to feel empathy or remorse |
| “We were never close” | |
| Separation/divorce/abandonment | Fracture of parent–child bond, especially in early childhood, can result in long-term anger, distrust, emotional distance, self-doubt, and antisocial behavior |
| Discord/domestic violenceCPS involvementAlcohol/substance abuse | These situations all may cause the following:Anxiety, fears for self and siblings, for victimized parentChronic sense of uncertaintyDifficulty concentrating |
CPS, Child Protective Services.
* These characteristics are often repeated in subsequent generations.
e-Table 6-2 Common Characteristics of Child-rearing Practices of Family of Origin of Poorly Socialized Adults*
* These characteristics are often passed on to ensuing generations.
e-Table 6-3 Character Traits and Historical Revelations of Parents/Caretakers Who Are Poorly Socialized or Have Character Disorders
| Traits | Revelations in History |
|---|---|
| Self-focused | Unable to truly love/care for another and put the other’s needs first |
| Everything they recount in the history is in relation to themselves | |
| Talk more about themselves than their child | |
| Jealous of spouse’s/significant other’s attention to the child | “She spends too much time with him/her”“She babies him”“She loves that kid more than me” |
| Jealous of child’s preference for spouse/significant other | “He’s a momma’s boy, always wants to be with/run to his mother”“He’ll come to me but then runs right back to his mother” |
| Psychopathic/sociopathic tendencies | Little or no conscience/capacity for empathy/remorse |
| No compunction about lying and lie quite convincingly | |
| Poor impulse control, short fuse, bad temper | History of behavior problems—fights, school suspensions |
| Take little or no responsibility for their own failures; instead blame others | Did not finish school “because the principal had it in for me”Cannot hold a job for more than a few months “because the managers are all nuts” |
e-Table 6-4 Mental Illness Seen in Some Abusive Adults
| Mental Illness | Characteristics |
|---|---|
| Severe depression | No energy, often cannot even get out of bed |
| Inability to nurture or relate | |
| Bipolar disease | Cycling of emotional highs and lows |
| Inconsistency (children never know what is going to happen next) | |
| Explosive behavior | |
| Schizophrenia | Hallucinations/delusions/psychosis: including voices postpartum saying the infant/child is “evil,” “must be punished,” “must die” |
Note: Often parents with mental illness are resistant to seeking and participating in therapy and to consistently taking their medications.
Child Risk Factors
2 Being separated at birth from a mother at high risk for problems with attachment because of illness or prematurity, resulting in impaired bonding.
3 Being the product of an unplanned/unwanted pregnancy, with a mother who sought little or no prenatal care.
4 Being small for gestational age, born with congenital anomalies, and/or having a chronic illness (possibly due to parental grieving and guilt, compounded by the chronic stress of caring for a handicapped child).
5 Being perceived as difficult or different.
6 Having attention-deficit/hyperactivity disorder (ADHD) or being oppositional or defiant.
Two situations place children at particularly high risk for abuse. One involves a couple with an unplanned pregnancy that one parent did not want and then pushed for abortion, and which the other insisted on carrying to term. After delivery, such infants can be at significant risk when left alone in the care of the parent who opposed the pregnancy. The other involves a common pattern in which a young (often teenage) mother who has trouble with attachment and low self-esteem mistakes “attention” and sex for love and, thus, has poor judgment in her selection of boyfriends. These young women may then have a revolving door for paramours who opportunistically move in for weeks to months and then leave only to be replaced by another. These men also tend to have attachment issues and often have poor impulse control. Further, they have no vested interest in her offspring by other men and thus may have no compunction about “batting them around” when they become a source of irritation, misbehave, or have accidents while these men are “babysitting.”
One common thread connecting all of these risk factors appears to be one of unmet expectations, due to either unrealistic parental expectations of the child or the child’s inability to meet realistic expectations as the result of developmental delay, illness, temperament, hyperactivity, or inconsistent disciplining. Typically this stems from lack of parental understanding of normal child behavior and emotional development, and of their children’s basic needs for nurturing. The combination can then lead the parent or caretaker to attribute malicious intent to an infant who will not stop crying or to a toddler who has had a toilet training accident, is stubborn, or misbehaves. Once “malicious intent” is suspected, this can incite rage in someone with a short fuse.
With this background information, the approach to diagnosis of the major forms of abuse can now be addressed more specifically.
Physical Abuse
Physical abuse is defined as the infliction of bodily injury that causes significant or severe pain, leaves physical evidence, impairs physical functioning, or significantly jeopardizes the child’s safety. Individual states have varying definitions of what constitutes abuse reportable to Child Protective Services (CPS) and law enforcement agencies, and practitioners should become familiar with the guidelines in their own states. Many of the methods used by perpetrators are listed in Table 6-1, and weapons commonly employed are detailed in Table 6-2.
Table 6-1 Methods Used in Physical Abuse
Table 6-2 Weapons Commonly Used in Physical Abuse
Infants and toddlers are at greatest risk for physical abuse because they are unable to escape attack, and are developmentally incapable of meeting many expectations and of knowing when to “keep a low profile.” Given their small size and physical immaturity, they are also the most vulnerable to severe injury. Common triggers for abusive behavior toward infants are crying, especially prolonged or inconsolable crying, and feeding problems. Crying may be due to hunger; pain with illness such as otitis media and esophagitis with gastroesophageal reflux; gas pain due to aerophagia either precipitated by or induced by respiratory disease or frequent feeding interruptions in avid feeders; and pain from prior inflicted trauma (rib or extremity fractures or CNS irritability from head injury). Feeding problems may stem from neurologic or oral–motor disorders, oropharyngeal deformities (such as cleft palate), or pain on swallowing due to oral lesions or reflux-induced esophagitis. With toddlers, difficulties in toilet training, toileting accidents, getting into things they are not supposed to touch, and stubbornness or negativism are common inciting factors. Failure to follow orders or instructions, oppositional or defiant behavior, and getting into trouble at school are notable triggers of abuse of older children.
The spectrum of severity of injuries caused by physical abuse ranges from isolated surface bruising that may be a product of overzealous discipline to fatal head and abdominal trauma that is the result of extremely violent rage reactions. Important to remember is that relatively unimpressive surface marks or injuries may be associated with far more significant underlying skeletal, abdominal, and CNS trauma (see Fig. 6-13). In addition, it is well known that physical abuse tends to be repetitive and that the severity of attacks tends to escalate over time; so does, correspondingly, the severity of injuries. Given this, early recognition, reporting, and intervention are essential in prevention of increased morbidity and mortality. Early recognition can be difficult for a number of reasons. Children with milder injuries generally are not brought to medical attention and may even be kept from those outside the immediate family until visible bruises or other surface injuries fade. Further, when care is sought, a misleading or deceptive history is almost always given. If a plausible history of accidental injury is provided (as can be the case with more sophisticated abusive parents), abuse may go unsuspected. However, when emergency department physicians make it a general practice to disrobe children and perform a complete surface examination on all those who present with mild or minor trauma, the diagnosis of otherwise unsuspected abuse rises dramatically because of identification of suspicious physical findings on other areas of the body, especially those ordinarily covered by clothing. Because presenting signs and symptoms are often nonspecific, recognition can be particularly challenging when the victim of mild to moderate inflicted trauma is a young infant and has no surface injuries or ones that are subtle and easily overlooked. Listlessness or lethargy, irritability or fussiness, vomiting (usually without diarrhea), low-grade fever, and vague complaints of trouble with breathing in infants with milder degrees of inflicted head injury can easily be interpreted as being due to early viral infection. Irritability due to pain from rib and metaphyseal fractures may be mistakenly diagnosed as due to colic or constipation (which may coexist due to stool withholding secondary to pain). Grunting respirations due to rib pain are likely to be attributed to early pulmonary disease such as bronchiolitis or pneumonitis. Relatively rapid dissipation of pain and tenderness (often within 2 to 5 days) in infants with nondisplaced fractures (due to their thick periosteal covering, which resists tearing and promotes prompt healing) can add to the diagnostic difficulty, particularly when presentation is delayed.
Hence diagnosis requires a high index of suspicion when infants, especially young infants, present with uneplained irritability and/or lethargy, with or without grunting respirations, and with vomiting without diarrhea. Unusual thoroughness in history taking and physical examination is a must. This includes asking if fussiness or irritability is or was worse with movement, on being picked up, or when held by the chest. The physical examination should include a meticulous surface assessment searching for faint bruises or petechiae including a Wood’s lamp examination (see the section Bruises, Welts, and Scars); careful palpation of ribs and extremities for tenderness (with particular attention to posterior ribs and long bone metaphyses); and dilated retinoscopy, all of which can be revealing. When a history of pain on motion or bony tenderness is found or when subtle surface injuries are noted, a skeletal survey is indicated, perhaps followed by a bone scan (see the sections on fractures, under Skeletal Injuries). The presence of metaphyseal and rib fractures and/or retinal hemorrhages mandates a head computed tomography (CT) scan (because of their association with subdural hematomas).
Of note, there is a demonstrated increase in admissions for serious inflicted injury of infants around 6 to 8 weeks of age. This has been attributed to a normal increase in crying from birth to 2 to 8 weeks “unrelated to any underlying pathology.” The majority of this crying does not have an identifiable cause and is observed across cultures. Given the fact that many, if not most, young infants admitted with serious inflicted trauma have evidence of prior painful injuries, often of differing ages, it is likely that the true cause of their crying went undetected. This could be because no prior care was sought or because when sought, signs of tenderness had abated, symptoms were nonspecific, or the exact cause was not assiduously sought and was therefore missed.
The disturbing incidence of severe and fatal cases of physical abuse has led to an effort to detect identifiable risk factors that might be predictive of fatal outcome. The majority of perpetrators of such abuse who have been studied were abused themselves as children. Poverty, unemployment, a long history of family violence, drug and alcohol abuse, and adolescent parenthood were common threads. Fathers and paramours are by far the most common perpetrators, responsible for up to 58% of the cases of severe and fatal beatings, followed by babysitters in up to 21% and mothers in up to 13%. Crying and toilet training accidents were the most common triggering events. Victims frequently had histories or evidence of prior suspicious injuries, often of a series of injuries of increasing severity, before the final beating. Mothers are more likely to be the perpetrators of death by suffocation and neglect.
The diagnosis of inflicted injury is established on the basis of a constellation of factors including historical, physical, and behavioral observations. Approaching the case with an open mind, obtaining a thorough present and past medical and psychosocial history, and meticulous physical examination are crucial to ensuring accurate diagnosis of inflicted trauma as well as in preventing overdiagnosis of abuse. Important elements are detailed in Tables 6-3 and 6-4. Radiographs and laboratory studies (complete blood count [CBC] and differential, liver function tests [LFTs], amylase, lipase, prothrombin time/partial thromboplastin time [PT/PTT], coagulation profile) are useful, not only in identifying and confirming injuries, but also in detecting evidence of occult trauma and ruling out other differential diagnostic possibilities.
Table 6-4 Physical Examination for Suspected Physical Abuse
Common Historical Red Flags
In many instances one or more of the following historical red flags may provide the first clue to abuse:
1 Despite no history of injury, injury is found.
2 The history is incompatible with the type or degree of injury. For example, the distribution of lesions or type of injury does not fit the mechanism reported; the history is consistent with a minor injury (shortfall, rolled off couch), but evidence of major trauma is found; or multiple injuries of differing ages are found for which no prior care has been sought or adequate explanation provided.
3 The history of the way in which the injury occurred is vague, or incomplete.
4 The history changes each time it is told to a different health care worker, or even to the same worker who comes back with clarifying questions.
5 The parents, when interviewed separately, give contradictory histories.
6 The history is not credible. The child may be said to have done something developmentally impossible (e.g., having climbed and fallen when he or she cannot even sit, or a younger sibling caused it).
7 No history is reported of changes in behavior in an infant or child who has older injuries of differing ages that would have caused significant pain.
Miscellaneous Historical Red Flags
1 A history or evidence of repeated visits necessitated by “accidents” or injuries (often to a number of different facilities).
2 A history or evidence of repeated fractures or old scars suggestive of prior inflicted injury.
3 A history of repeated ingestions.
4 Poor compliance with well-child care: missed visits, immunization delay.
Behavioral/Interactional Red Flags
1 A significant delay between the time of injury and the time of presentation often exists.
2 The parent may not show the degree of concern appropriate to the severity of the child’s injury.
3 A pathologic parent–child interaction may be observed. A parent demonstrates unusually rough/angry/impulsive behavior toward the child (yells, yanks, hits). A parent displays inappropriate expectations of child (“sit still,” i.e., don’t explore; “watch your brother”). A parent is often clearly unaware of the child’s needs and insensitive to behavioral cues (crying with hunger, dirty diaper, wants to be held or comforted).
Few victims of physical abuse are brought in with a chief complaint of abuse. Most present with a chief complaint of an accidental injury or of an unrelated (cold, rash) or somewhat peripheral (lethargy, irritability) chief complaint. Whenever the physician’s suspicion is aroused by historical or observational findings, he or she (or a designated social worker) should obtain a detailed psychosocial history, seeking more information concerning the family’s current living situation, stresses, and emotional support systems. Particular attention should be paid to recent family crises including personal (ill health, job loss, separation) and environmental (pending eviction, heat or utilities discontinued) crises; degree of isolation (no family or social supports, no phone); and prior problems with family violence, mental health, alcohol, or drugs. Answers to questions about methods of discipline and parental reactions to common triggering events such as prolonged crying, toilet training accidents, and stubborn behavior can be most illuminating, as can answers to questions about how they felt when they learned of the baby’s pregnancy, when they first saw the baby, and what the baby is like (see Table 6-3). Although a detailed history takes time, it can be invaluable in facilitating accurate diagnosis, individualizing care, arranging appropriate family supports, and assisting CPS and law enforcement in their investigations. This and the medical history should be obtained in a supportive, nonjudgmental manner because aggressive interrogation will only serve to alienate the parent, limiting the value of the data obtained.
Table 6-5 presents additional historical and behavioral clues that may become apparent in the course of interviewing the parents/caretakers of an abused child.
Table 6-5 Historical and Behavioral Clues from Caretakers’ Demeanor during Interview
Note: Perpetrators often disclose a watered-down version of what they did when abusing the child when asked what they think might have happened to cause the injuries found.
In approaching abused children, one must recognize that their parents are the only ones they know; that they love them and, usually, their other caretakers; and that at times, they may even feel in some way deserving of abuse. Young children rarely acknowledge that a parent or other caretaker has injured them, especially when questioned directly, often because they have been threatened or sworn to secrecy. If they can be interviewed alone (when old enough to give a history) in pleasant, nonthreatening surroundings, helpful historical information can often be obtained by means of nonleading questions and through drawings or play. In some cases in which the perpetrator is a paramour of the mother, and has not been around long, the child may be more willing to disclose, especially when he or she can honestly be reassured that they will have no further contact with him and is, therefore, safe from further assault.
It is also important to remember that siblings, especially older siblings, can often provide useful historical information. Strong consideration should be given to interviewing them as soon as possible after abuse is identified. Their histories can be quite helpful, and they may prove to be good witnesses in subsequent hearings.
Physical Findings and Patterns of Injury
Surface Marks
The most obvious manifestations of physical abuse are those visible on the surface of the skin. They include bruises, welts, scars, abrasions, lacerations, tourniquet and bite marks, and burns. Despite differing opinions on the appropriateness or inappropriateness of physical methods of discipline, there is a good rule of thumb in distinguishing the boundary between discipline and abuse: Discipline does not inflict significant pain and does not cause physical injury or leave marks.
All external signs of trauma found should be carefully documented in writing, on body diagrams, and in photographs (preferably with a ruler and color wheel in the frame).
Bruises, Welts, and Scars
Bruises are the most common clinical finding in cases of physical abuse, seen in up to 75% of victims, and their presence should prompt a search for other, deeper injuries. Inflicted bruises and welts may be the result of direct blows or of impacts with firm objects when pushed, shoved, thrown, or swung into them. They frequently involve more than one plane of an extremity, the torso, and/or head, and are often found in places that are unusual sites for accidental injury (see the section Differential Diagnosis of Inflicted Injuries versus Findings Caused by Accident or Illness, later). These include the back, buttocks, upper arms, thighs, abdomen, perineum, and feet, all of which are typically covered by clothing and, thereby, hidden from public view (Figs. 6-1 and 6-2). When due to slaps or blows, these locations suggest some forethought in site selection. Among other unusual sites are the face (including the periorbital area and eyelids, cheeks, sides of the forehead, lateral aspects of the chin and mouth), ears, neck, hands, calves, and volar or ulnar (defensive posture) aspects of the forearms. Being more exposed, bruises in these areas may reflect greater impulsivity on the part of the perpetrator.
Figure 6-1 Inflicted bruises found in unusual locations. A, Multiple ecchymoses are evident over the back and upper chest of this child who presented in a poorly nourished condition. B, The same patient with multiple bruises involving differing planes of the face and forehead. Note the fingerprint bruise on the cheek. C and D, This child had severe contusions over the hands and feet, which were inflicted with a ruler. E, He also had a markedly swollen and contused ear and patches of hair loss where the perpetrator had pulled out hanks of hair. Both boys had been removed from abusive mothers and placed with maternal grandmothers who had physically abused their daughters in the past.
Figure 6-2 This toddler, the victim of repetitive beatings by her mother’s boyfriend while the mother was hospitalized, had A, postauricular bruising, B, a line of fingerprint or knuckle bruises over the posterior left shoulder, and C, extensive bruising over the lower back in a pattern suggestive of knuckle marks, along with a large contusion over the right iliac crest. D, Rounded bruises over the lower abdomen and mons pubis may represent grab or punch marks. Some of her injuries were due to impacts against stairs and furniture when thrown forcefully by the perpetrator. Other injuries included a healing left radius fracture, refracture through a healing distal clavicle fracture, and evidence of old CNS trauma (see Fig. 6-26; Fig. 6-39, B; and Fig. 6-55).
Bruises involving the head, face, mouth, neck, and ears (Fig. 6-3) are seen in a substantial percentage of physical abuse victims: approximately 50% of infants and 38% of toddlers. Subgaleal hematomas and contusions and petechiae involving the scalp may be the result of direct blows or impacts against hard surfaces. On occasion they are caused by forceful hair pulling (Fig. 6-4). Slaps of moderate force may produce diffuse bruising with petechiae (Fig. 6-5). More forceful slaps leave handprint marks, consisting of petechial outlines of the fingers of the perpetrator as maximal capillary distortion occurs at the margins of the fingers on impact (Fig. 6-6). Periorbital and eyelid bruises in the absence of evidence of an overlying forehead hematoma or abrasion, or of an accidentally incurred frontal skull fracture, are likely to be inflicted and caused by direct blows to the face (Fig. 6-7, A and B).
Figure 6-3 Ear bruising. This infant was hit so forcibly on the side of his head that he has an impression bruise on his scalp in the shape of his external ear. The linear bruise over the top rim of his ear is the result of capillary distortion caused by compression between the impacting hand and the child’s skull.
Figure 6-4 Subgaleal hematomas. This toddler, in the care of mother’s paramour, was reportedly well until about 45 minutes after being put to bed, when she “woke up screaming.” On being picked up, she was noted to have a “mushy head.” At the hospital, she was found to have large bilateral subgaleal hematomas, with surface bruising and petechiae over the occipitoparietal scalp. She also had semicircular bruises behind her left ear consistent with fingernail marks. Skull radiographs and a head CT scan showed no evidence of skull fracture or intracranial injury. Further examination revealed extensive bruising and lacerations of the introitus consistent with sexual assault (see Fig. 6-92 B). The perpetrator apparently grabbed her by her hair and by her head, leaving fingernail marks while in the process of assaulting her. Her hair was pulled so forcibly that the scalp was pulled away from the skull, leading to the extensive subgaleal bleeding, which continued to expand over the ensuing 72 hours. A, Thinning of the hair from hair loss and bruising of the scalp are evident, and the subgaleal hematoma over her left temporal area is so large that it is pushing her external ear out laterally. B, Curvilinear marks behind her left ear are fingernail impressions.
Figure 6-5 Facial slap marks. A, Diffuse facial bruising and petechiae seen over the side of the face and head of this 3-week-old infant were the result of repeated slaps by his father, a paranoid schizophrenic who had stopped taking his medication. He acknowledged slapping his son to make him cry, after which he would give him his bottle, the purpose being to teach him to cry when hungry. The baby also had metaphyseal chip fractures due to forced hyperextension of the knees to the point of screaming because “his muscles were tight” and “needed to be loosened up.” B, This older infant has even more extensive petechiae and bruises that were tender on palpation.
Figure 6-6 Handprints. A and B, These children were slapped so forcefully that the outlines of their abuser’s fingers are clearly evident.
Figure 6-7 A, Bilateral black eyes are seen in this 12-day-old baby. His father, who was well-to-do, well dressed, and sophisticated, reported that he had fallen on the stairs while holding the baby in a football hold and that in the fall, the baby hit the steps face first with father landing on top of him. Bruises involving multiple planes of the face, the absence of an associated forehead hematoma or frontal fracture, and the presence of an occipital fracture consistent with impact against a hard surface (not the father’s chest) belied this story. Nevertheless, abuse was not suspected, and the baby was sent home. He returned 6 weeks later in extremis with massive intracranial injury and died. On this occasion, the father said he had found the infant choking and gasping for breath and had picked him up and shaken him to revive him. B, This infant’s bilateral black eyes are the result of direct blows to the periorbital areas bilaterally.
Surface injuries involving more than one plane of the head or face are highly suspicious for abuse. It is also important to recognize that contusions of the head, face, and ears are often associated with underlying intracranial injury, especially in infants. Such injuries are indicative of severe loss of control and intent to harm on the part of the perpetrating caregiver and have serious implications for the child’s future safety unless he or she is removed from contact with the offender.
Round impressions of the thumb and forefinger may be seen on the cheeks, sides of the forehead, or sides of the chin in infants and young children who have been grasped and forcefully squeezed (see Fig. 6-1, B). Similar fingerprint bruises may be noted on the upper arms, trunk, abdomen, or extremities where the infant has been grasped and held tightly while being shaken or forcibly restrained (see Fig. 6-13). More elongated grab marks may also be found on the extremities (Fig. 6-8). When round bruises similar to fingerprint marks are found in a linear pattern, they may be fingertip impressions or knuckle marks from punching (see Fig. 6-2, B and C). In the latter instance, one may note partial central clearing of the rounded contusions. Fingerprints or grab marks located on the thighs, especially the medial surfaces, should prompt careful examination for signs of concurrent sexual abuse. Pinching produces apposed fingerprint marks with a shape that may be reminiscent of a butterfly or figure-of-eight. These may be seen singly or in rows, usually on clothing-covered areas (Fig. 6-9).
Figure 6-8 Linear finger grab marks are seen on the outer aspect of this infant’s upper arm. A thumbprint bruise was present medially.
(Courtesy Kent Hymel, MD, Inova Fairfax Hospital for Children, Falls Church, Va.)
Figure 6-9 Pinch marks. A row of fading bruises secondary to pinching, used as a method of discipline by his mother, is seen on the lateral aspect of the thigh of this preschool-age boy. More than a year later, his sister nearly died of multiple stab wounds also inflicted by their psychotic and delusional mother (see Fig. 6-16).
Attempted smothering, choking, or severe and prolonged thoracic compression may produce showers of petechiae over the shoulders, neck, and face (Fig. 6-10, A–D). The oral and conjunctival mucosa may be involved as well and should be carefully inspected. If a hand or other object is held forcefully over the nose and mouth of a child with erupted teeth, imprint bruises, abrasions, or lacerations left by the teeth on the labial mucosa may be noted in addition to facial petechiae (see Fig. 6-10, E). When strangulation is the mechanism, neck bruises are usually visible (see Fig. 6-10, B). These petechiae may range from florid to faint and may be especially subtle when there has been a delay in seeking care. They can be mistaken for a rash if the examiner fails to check for blanching. Failure to detect such lesions has resulted in a number of subsequent deaths.
Figure 6-10 A–D, Petechial lesions secondary to choking. A, Numerous petechiae are seen over this boy’s face. B, Linear marks noted on the side of his neck correspond with the hand and finger placement demonstrated in C and D. The boy was choked to a point of near-unconsciousness by his mother’s boyfriend for tracking grass onto a freshly vacuumed carpet. E, Central facial petechiae were present bilaterally in this infant. The perpetrator confessed to holding his hand over her mouth and nose and squeezing her cheeks with thumb and forefinger to stop her crying.
(Courtesy Kent Hymel, MD, Inova Fairfax Hospital for Children, Falls Church, Va.)
Bruises are often seen over the curvature of the buttocks and across the lower back after severe spankings, whether with a hand or an object such as a paddle, belt, or hairbrush (Fig. 6-11). When linear marks from fingers, belt, or brush edges are seen, these tend to be horizontally or diagonally oriented (see Fig. 6-11, B). However, in some cases a linear pattern of petechiae may be noted on either side of the gluteal crease (see Fig. 6-11, C). Despite their vertical orientation, these are also the result of forceful horizontal blows across tightly tensed glutei, as when the blows are delivered, the involved sites are closely apposed along the crease and thus are subject to maximal capillary distortion on impact.
Figure 6-11 Buttock bruises. A, At first glance, this toddler appeared to have a diaper rash, but on closer inspection the lesions were found to be petechiae produced by a severe spanking. B, The severe contusions of the buttocks and lower back seen in this child were inflicted by hand, hairbrush, and belt. C, A linear pattern of petechial hemorrhages is seen on either side of the gluteal cleft in this boy who was subjected to repeated rapid-fire blows across the gluteal crease.
Bruises involving the abdominal wall below the rib cage and above or anterior to the pelvic girdle are rarely seen with accidental injury and are relatively unusual in cases of abuse (see Fig. 6-2, D and Fig. 6-13). This is because of the great flexibility of the abdominal wall and its padding with adipose tissue. In fact, many children with inflicted intraabdominal injuries have little or no cutaneous evidence of trauma over the abdomen, although in some cases their absence may be due to delayed presentation. When abdominal bruises are present, they are indicative of forceful grabbing or pinching or of forceful blunt impact (such as a punch or kick). In these cases, abuse should be strongly suspected and evidence of internal injury should be sought (see the section Abdominal and Intrathoracic Injuries, later; and Fig. 6-57).
In many instances the surface marks are recognizable imprints of the edge of a weapon used to inflict the injury, because the edge causes maximal capillary deformation on impact. Those most commonly seen are looped-cord marks, caused by whipping the child with a looped electrical cord (Fig. 6-12, A and B), belt and belt-buckle marks (see Fig. 6-12, C, D, and F; see also Fig. 6-11, B), and switch marks (see Fig. 6-12, E and F); but almost any implement can be used including hairbrushes (see Fig. 6-11, B), shoes (see Fig. 6-12, G and H), kitchen utensils (see Fig. 6-12, I), and chains (see Fig. 6-12, J).
Figure 6-12 Imprint marks reflecting the weapons used to inflict them. A, Fresh looped-cord marks and B, hypopigmented and hyperpigmented scars that were the result of beatings with a looped electrical cord. C, The characteristic pattern of parallel lines that results from blows with a belt. D, This contusion in the configuration of a closed horseshoe with a central linear abrasion was inflicted with a belt buckle. E, The red linear contusions on this child’s thigh were the result of repeated blows with a switch. F, These acute linear contusions over the back and buttocks were inflicted with a belt and a switch. G, This boy was hit with a slipper with such force that imprints of the heel are evident. H, The heel prints of a running shoe left on this boy’s arm and thigh were distinct enough to enable identification of his abuser. I, This girl was hit forcefully with a spatula because she was acting out while her mother was trying to prepare dinner. J, This boy was struck with a chain, leaving a clear imprint of the links.
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