Child Maltreatment
Adrienne D. Atzemis
Jamie S. Kondis
It is important to remember that child maltreatment is a common cause of childhood morbidity and mortality, leading to more than 1,500 child deaths per year in the United States. Failing to recognize signs and symptoms of child maltreatment and appropriately respond can result in death. Types of child maltreatment to be familiar with are:
Neglect: A child is not provided with adequate basic needs, such as safety, nutrition, housing, education, medical, and dental care.
Physical abuse: A child is physically harmed by another’s nonaccidental actions.
Sexual abuse: A child is subjected to developmentally inappropriate sexual material or activities by someone in a caretaking role or is subjected to sexual activity without his or her consent.
Caregiver-fabricated illness: A child is subjected to unnecessary medical care because of a caregiver’s fabrication, exaggeration, or inducing of symptoms.
Emotional abuse: A child is emotionally harmed by a caretaker’s actions or verbal statements.
It is estimated that 1.25 million children are victimized by some type of child maltreatment each year. Maltreatment spans all social, economic, educational, racial, and cultural spectrums, although there are risk factors for an increased incidence, including:
Child factors: Young age, unplanned or unwanted pregnancy, prematurity, developmental delay, cognitive impairment, and having a “difficult” temperament
Caregiver factors: Social isolation, mental illness, substance abuse, personal history of victimization, poverty, lack of parenting skills, and unrealistic expectations of child
Community factors: Violence, poverty, lack of resources, and failure to address community needs
MANDATORY REPORTING OF CHILD MALTREATMENT
Laws for reporting child maltreatment vary from state to state, but in every US state, medical providers are mandated to report child maltreatment.
Healthcare providers should be aware of their legal obligations as mandated by their country or state, as well as their institutional policies addressing abuse concerns.
Failure to report abuse can result in fines and/or imprisonment and/or loss of medical license.
RECOGNIZING AND RESPONDING TO NEGLECT CONCERNS
Types of neglect are physical, supervisional/abandonment, endangering/safety, emotional, educational, and medical/dental.
Neglect may manifest as inadequate hygiene (child is obviously smelly or filthy), or poor hygiene may contribute to medical problems, such as a wound infection.
The child may be wearing clothing that are too small or are inappropriate for the environment.
A child’s injuries may be the result of inadequate supervision, or the family may delay in seeking care for the injuries.
RECOGNIZING AND RESPONDING TO PHYSICAL ABUSE CONCERNS
A provider’s ability to correctly recognize child physical abuse is first dependent on his or her willingness to accept maltreatment as a potential cause of a physical finding.
It is then dependent on the provider to recognize concerning elements of the history and recognize suspicious physical findings.
Concerning history:
No history to account for an injury
Delay in seeking medical care
Past history of abuse
Substantial variation in the history, either by the same caregiver over time or by two different caregivers
The history provided is implausible.
The history lacks contextual details.
The historian gives a vague timeline.
Concerning injury:
The injury is discordant with the developmental stage of the patient.
There is a proposed minor mechanism leading to a major injury.
The injury is patterned or geometric.
The injury has sharply demarcated borders or transition zones.
The injury site(s) are unusual for an accidental injury.
There are multiple sites, types, or stages of healing injury.
The injuries are bilateral or involve multiple planes of the body.
Many communities have identified local experts who are experienced providing medical care to victimized children within the context of local legal regulations and expectations. Inexperienced providers are encouraged to utilize the assistance of local experts before a final diagnosis is provided.
Presume that the medical record will be reviewed by local investigatory agencies and may be used in legal proceedings. Therefore, ensure that the record is complete and legible and provides enough information for nonmedical professionals to reasonably understand the findings.
Bruises
Bruises are common is active healthy children and are also the most common presenting injury in an abused child.
See Table 12-1 for common characteristics of abusive versus accidental bruises.
Fractures
Fractures are the second most common injury caused by child abuse.
Abusive fractures are frequently occult and do not have overlying bruise.
Any fracture type may be inflicted, but there are fractures that are considered highly specific for an inflicted mechanism including:
Classic metaphyseal lesion (CML), aka corner fracture, or Bucket-Handle fracture are highly specific for abuse in infants <1 year old and most common in <6 months old.
Rib fractures: Abusive rib fractures can result from compression of the chest or a direct impact. Posterior rib fractures are typically caused by an anterior-posterior squeezing of the chest.
Scapular fracture
Spinous process fracture
Sternal fracture
Fractures that are considered moderate specific for inflicted mechanism are:
Multiple fractures, especially bilateral
Fractures of different ages
Epiphyseal separations
Vertebral body fractures and subluxations
Digital fractures
Complex skull fractures
Fractures that have low specificity for abuse and are commonly accidental in nature include:
Clavicular fractures
Long bone shaft fractures
Supracondylar fracture
Linear skull fractures
Both accidental and abusive fractures can be transverse, oblique, or spiral and depend on the direction of forces during the trauma mechanism. A spiral fracture can result from any rotational movement of a limb, which can occur in both accidental and abusive events.
A medical evaluation into possible medical disease leading to brittle bones or other bone disease that can be misinterpreted as fracture should be performed if there is medical indication that such a condition exists.
TABLE 12-1 Common Characteristics of Abusive versus Accidental Bruises | |||||||
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