Children are dependent on their carers for their physical, emotional and developmental needs, their supervision and safety. It is hard to understand that adults can harm children—yet this occurs commonly. Abuse is typically carried out by family members or friends who have close contact with children. Health professionals need to understand the different presentations of child abuse and how to work with agencies to safeguard children.
How Does Child Abuse Present?
Child abuse can present in many ways. Some of the more common scenarios are:
- A parent or teacher seeks help following an episode of abuse which the child has disclosed.
- Families present a child to primary care or the emergency department with non-specific signs of illness or injury. Evaluation reveals inconsistencies in the history, background social risk factors or physical signs which indicate abuse.
- Physical signs of abuse are detected during routine contacts.
- Abused children may have emotional or behavioural problems such as poor mood, anxiety, poor social interaction, attention problems, aggressive behaviours, sexualized behaviours.
Physical injuries are usually inflicted when adults lose emotional control while caring for babies and children. Risk factors include parental stress, substance abuse, poor social support, and situations where parents have suffered abusive experience in their own childhood. Injuries can occur with premeditation such as deliberate physical punishment. Injuries may range in severity from minor bruises to fatal brain or abdominal injury. Injuries may recur over an extended period of time, through years of childhood. A child who has suffered a minor abusive injury is at risk of a future severe injury.
Any type of injury may have an abusive cause and there may be many different mechanisms including; punching, slapping, kicking, biting, hitting with an object, abdominal trauma, fractures, shaking, burns, scalds, asphyxiation, poisoning.
Factors that indicate abusive injury include:
- Carer conceals injury
- Delay in presentation for medical assessment of injury
- Unusual or inconsistent history of mechanism of injury
- Multiple injuries
- Different age injuries
- Some specific injuries are typical of abuse
- Previous social concerns
- Child discloses abusive injury.
Some injury patterns are more highly suggestive of abuse:
- Bruises: distinctive shapes such as bite marks, multiple bruises in young babies, unusual sites on the body
- Burns: cigarette burn, immersion hot water scald injuries
- Fractures: young babies, multiple fractures, different age fractures
- Shaken baby pattern: subdural haematoma brain injury with retinal haemorrhages and skeletal fractures.
Neglect is inadequate care which can result in serious harm to a child. Basic care is to provide food, warmth, clothing, hygiene, dental care and immunizations, and to seek medical attention for an illness. Parents should act to protect children from harm by injury. Basic care involves good parenting behaviours including establishing boundaries relating to children’s behaviour and a healthy lifestyle of diet, exercise, activity.
Neglect and Failure to Thrive
Some young children fail to thrive with poor nutrition. Good infant feeding requires a good emotional interaction during the feed. Parents need to be responsive to the child, manage periods of difficulty, seek advice if there are problems. This can be impaired if parents have poor models of parenting, social stresses, mental health problems or substance abuse problems.
Children can present with problems of faltering growth, acute illness and developmental problems. If admitted to hospital these babies often show rapid weight gain. Catch-up growth may occur but brain development may be disrupted. Subsequent emotional and educational problems are common.
Attachment is the close emotional bond which binds families—the relationships in which children learn skills for future relationships and independence. Quality of attachment depends on quality and consistency of parent–child interaction.
Children suffer emotional abuse if exposed to persistent or severe ill-treatment with dysfunctional parental responses such as rejection, excessive punishment, isolation, scapegoating, manipulation or overprotection. Emotional abuse also includes giving children inappropriate responsibilities and allowing children to witness harmful adult actions such as domestic violence.
The consequences of emotional abuse are profound. Children fail to learn normal emotional responses. They may develop problems in empathy, self-esteem, resilience and independence. There is usually significant emotional abuse in all forms of physical abuse, sexual abuse and neglect.
Sexual abuse is inappropriate sexual behaviour involving a child such as exposing a child to pornography, sexual touching, involvement in sexual acts, vaginal, oral or rectal intercourse. Perpetrators are most commonly family members or acquaintances. Perpetrators befriend (‘groom’) children to create situations of close contact. Perpetrators use threats to discourage children from disclosing abuse and may give children drugs or alcohol.
Sexual abuse is disclosed if a child talks about what has happened. An abused child may demonstrate inappropriate sexual language or behaviour in their play. Abuse may be suspected from a pattern of soft tissue trauma (mouth, anus or genitalia) or infection. Abuse can cause non-specific illness symptoms or behavioural problems. If children feel safe they may be able to tell a trusted adult relative or teacher that someone has hurt them. Staff need to be able to talk to children in a way that lets them disclose what has happened through open and supportive questions.
Sensitive, skilled medical management is required. General examination and anogenital examination with a colposcope is performed to document injuries and obtain photographic and forensic evidence. Following sexual abuse, physical signs are commonly absent.
Victims of abuse need future safeguarding and follow-up psychological support to address the emotional harm of the abuse.
Factitious or Fabricated Illness
There are situations where adults present children for medical investigation with illness symptoms or signs that have been fabricated. This can lead to extensive medical investigation which can physically and emotionally harm the child. There are complex reasons for these behaviours—possibly a form of inappropriate care-seeking behaviour which may reflect a background personality disorder.
A full skeletal survey radiography series is performed in infants where there is concern about previous physical abuse. Brain imaging and ophthalmology review are performed to investigate for shaking injury.
From the medical assessment, it is usually possible to differentiate between abusive injuries and rare disorders that predispose to fractures or brain injury.
Blood tests to exclude haematological problem such as coagulation or platelet disorder may be performed in children with bruising injuries.
Screening for sexually transmitted infection, pregnancy and forensic testing may be performed following sexual abuse.
The Safeguarding Process
Professionals must report incidents that raise concern to the statutory authority with responsibility for child welfare. In the UK it is the local authority social services department that will investigate a situation of concern. It is best practice to keep families informed at all stages of the process and communicate clearly why actions are being taken.
Medical assessment is part of the investigation of a concern. Careful documentation of the history (including the child’s own words), examination and medical investigation is essential. The paediatrician gives an opinion on the features in the history and examination findings. Background information is shared with other professionals such as health visitors, nursery nurses, social workers, the GP and school. This gives a picture of the risk factors in the family and any previous concerns. A multi-agency case conference meeting is held to review the combined assessments, decide the level of risk and agree how to protect the child.
If a child is at risk then a safeguarding plan is put in place with key professionals to work with the family and monitor the future welfare of the child. In many situations it is possible for the child to remain in the care of their family. However, some children are at risk of serious harm with background factors that cannot be resolved. In the most serious cases a court may need to consider whether the child should be removed from the family by court order and looked after by the local authority, usually in foster care. Children in long-term care have better outcomes if permanent adoption into a new family can be arranged.
Characteristics of non-accidental injury:
- Injuries in very young children.
- Explanations that do not match the appearance of the injury, and which change.
- Multiple types and age of injury.
- Injuries that are ‘classic’ in site or character.
- Delay in presentation.
- Disclosure by the child.