Appendix 4 - Signs and Symptoms of Child Abuse and Neglect

Contents

1.0	Presentation of Injury
2.0	Physical Injuries
3.0	Neglect and Failure to Thrive
4.0	Emotional Harm
5.0	Sexual Abuse
6.0	Common Family Characteristics

1.0 Presentation of Injury

There are certain parental responses which are known, by research and experience, to suggest a cause for concern. These include:

2.0 Physical Injuries

Head Injuries

The most serious of head injuries are likely to lead to the largest group of fatalities. Injuries may result from a direct blow, swinging around or shaking.  The latter may cause serious injuries particularly in very young children and babies.

The child may present in a coma or with convulsions or sign of raised intra-cranial pressure (vomiting, headache and irritability), this may be secondary to a subdural haematoma.  This may occur with/without a fracture and any fractures will be identified radiologically.

Retinal haemorrhaging is generally associated with shaking injuries and examination with an ophthalmoscope should always be undertaken.  In addition, formal referral to a consultant opthalmologist may be wise subsequently.

If the child survives, he or she may become permanently disabled, for example, blind, paralysed and/or mentally impaired.

Fractures of the Long Bone

Fractures should be suspected if there is pain, swelling and discolouration over a bone or joint. The most common non-accidental fractures are to the long bones (i.e. arms, legs, ribs).  Fractures normally cause pain and it is difficult for a parent to be unaware that a child has been hurt.

It is virtually impossible for a baby to break an arm, leg or rib except in exceptional circumstances.  It is important to take a good history and to check the carer's story against the injuries found.  A vague history of "must have hit his/her head on the cot bars" or maybe "falling downstairs" will be suspect.

Fractures of long bones may be caused by pulling, twisting or squeezing.  This may cause spiral fractures in the middle of the bones or metaphyseal fractures at the end of the long bones.  These injuries may result in a minimum of physical signs and may only be identified by x-ray.  After injury blood leaks through the periosteum and starts to calcify. This can be detected by serial x-ray following injury.

Any child with a fracture suspected of being caused non-accidentally and any infant where suspicion is aroused should have a radiological skeletal survey to identify previous healed fractures or to eliminate this possibility.

Rib Fractures

Rib fractures can be caused by compression or pushing from side to side.  These are very suspicious in young children.  A great deal of force has to be used to produce such fractures (even cardiac resuscitation rarely results in rib fractures in young children).  The child may show no other evidence of squeezing such as grip marks of thumb and fingers to the back and chest.  Multiple fractures in a child under two years is very suspicious of non-accidental injury.

Rib fractures in acute stage are very rarely seen on a chest x ray, hence, if there has been serious injury or there is evidence of bruising around the chest which suggests there may have been squeezing or compression, a repeat x ray 10 - 14 days later would be good clinical practice and may show healing fractures.

Damage to Internal Organs

Punching, kicking and squeezing may damage any of the abdominal organs particularly the kidneys, spleen, duodenum or liver.  There is a high morbidity and mortality rate.  Such injuries are rare in the very young and almost always evidence of abuse.

Burns and Scalds

These are common injuries amongst young children. It can be very difficult to distinguish between accidental and non-accidental burns, but as a general rule, burns or scalds with clear outlines are suspicious, e.g. a gloves and socks effect. So are burns of uniform depth over a large area.

It is important to take a careful history and to think how the injury may have occurred.  For example, if a child puts a hand into hot water, they would immediately pull the hand away.  Symmetrical burns or scalds to both feet or hands are suggestive of non-accidental injury.  If a fluid or object is very hot, the child would be able to sense the heat so would be unlikely to submerge the limb very far.  If the injury involves the whole of both hands or feet, you should question how this came about.  Burns to the buttock, groin or perineum may be caused by dunking.

Occasionally children are scalded by being placed in a bath with a hot tap running.  This may or may not be accidental and detailed accounts of what happened should be taken. A child is unlikely to sit down, voluntarily, in too hot a bath and cannot scald its bottom accidentally without also scalding its feet. A child getting into too hot water of its own accord will struggle to get out again and there will be splash marks.  A responsible adult checks the temperature of the bath before a child gets in.

Children can receive serious scalds to the face, upper arms and chest while pulling a boiling kettle or other hot substances over themselves.  However, if splash marks cover a wide area be suspicious that the fluid may have been thrown.

Deliberate cigarette burns usually leave a round, deep burn which is very different from a casual contact with a cigarette end. It is sometimes difficult to differentiate between impetigo and cigarette burns - but generally impetigo is multiple and increases even during early stages of treatment.

Bruising

This is probably the most common injury seen.  Most children suffer from bruises received from falls during play.  These are most common over bony prominences (contact areas) such as shins.  They are usually quite innocent.  Check that they are compatible with the story given by the carers and the child, if old enough to say what happened. A child who falls downstairs generally has only one or two bruises. Bruising in accidents is usually on the front of the body, as children generally fall forwards. In addition, there may be marks on their hands if they have tried to break their fall.

The following are uncommon sites for accidental bruising:

N.B. Harmless "Mongolian blue spot" may be mistaken for fresh bruises in African or Asian children.

If the child is below six months of age be very suspicious.  Babies of less than four or five months cannot roll and it is difficult for them to injure themselves in this way.

Petechial haemorrhage (pin-point haemorrhage of the face and neck) can indicate a serious shaking injury.

Small bruises on the head and face of a young child often indicate feeding problems.  The child may be grasped on either side of the mouth leaving fingermark bruising. 

A torn frenulum could indicate a non-accidental injury but it may be the result of a direct fall onto a hard surface.  Multiple tears of the frenulum are suspicious.  A torn frenulum in the very young child is likely to be an indication of aggressive forceful feeding. Bleeding from the mouth in a young baby should always be taken seriously.

Bruising of the ear may result from pinching or twisting injuries to the pinna.  Alternatively a blow to the head may result in petechia haemorrhaging in or around the ear and on the scalp.  It is not uncommon to see linear bruising on the cheek adjacent to the ear following a slap to the face. The blow may be single or multiple and may involve the other ear as well.  A heavy blow may cause perforation of the ear drum (haemotympanium) and otoscopic examination should be carried out in all cases.

Bruising of varying ages in the same child should arouse suspicion of repeated abuse. 

In the absence of major trauma, two black eyes are highly suspicious if the lids are swollen and tender and there is no bruising to the forehead or nose. Black eyes can also be caused by blood seeping down from an injury above, e.g. a skull fracture - in these cases, there will be little lid swelling.

Finger marks on the back and trunk associated with grasping and shaking should always be looked for.

There may be a direct impression or outline bruising (e.g. belt marks, hand prints) or linear bruising (particularly on the buttocks or back);

Moderate injuries, particularly bruising, are the most common injuries found and should be evaluated carefully.  If significant bruising is found, a full blood count and platelet level should be estimated to exclude bleeding disorders. 

Bite Marks

These can leave clear impressions of marks of individual teeth, or sometimes a more general crescent-shaped mark. Human bites are oval or crescent shaped. If the distance is more than 3 cm across, they must have been caused by an adult or older child, with permanent teeth.

In suspicious cases the advice of a forensic orthodontist can be helpful.

Poisoning

Carelessness may make it easy for a toddler or a child to gain access to household items such as bleach.  Equally they may be able to obtain medicines such as antibiotics or adult tablets from parents pockets or handbags which are carelessly left about. However ingestion of tablets, medicines, or domestic poisons may not always be due to accidental carelessness. A parent may administer tranquillisers or sedatives to a child leading to drowsiness, unsteadiness and coma.  This is fairly rare but if there is evidence of this, samples of the child's vomit and urine should be retained for analysis. Be particularly cautious of the parents are known to, or appear to, abuse drugs or alcohol.

Hypernatraemic

This can result from parents making over concentrated feeds out of ignorance, or malicious intent, or from withholding fluid from a child, or by the addition of salt to feeds. Hypernatraemic dehydration can arise accidentally, however, and this should be excluded.

3.0 Neglect and Failure to Thrive

A child's growth and development may suffer when he/she receives insufficient food, love, warmth, care and concern, praise and encouragement or stimulation. A child who is unprotected from cold, hunger and danger is a neglected child, as is the child who is chronically under stimulated.  Children of all ages can be neglected but the neglect of a very young child may be life threatening and may cause lasting psychological damage.

Neglect checklist:-

4.0 Emotional Harm

Emotional abuse can exist in the absence of physical ill-treatment. A child's need for love, security, encouragement, praise and stimulation when unmet, can have a serious and sometimes irreparable effect on the child's development. Parents may be hostile, rejecting, indifferent, or, inconsistent and unpredictable in their response to their child.

The entire range of behavioural disorders in children may indicate emotional abuse e.g. abnormal aggression, indiscriminate affection, sleeplessness, night terrors, gorging, food refusal, attention seeking, bed-wetting and soiling. 

In some families, one particular child may be singled out and even siblings encouraged to scapegoat their abused brother or sister. Some children may have to carry the burden of many tasks in the home, inappropriate to their age and status.

Some parents emotionally abuse their children by being seriously overprotective and possessive to the extent of preventing normal social contact and activity with friends. This may extend to refusing to allow their children to attend school, or a reluctance on the part of the child to attend.

Children can be affected by domestic abuse without being touched, by seeing or hearing the abuse of another.

Emotional abuse is generally difficult to evaluate, and where it is suspected, it is advantageous to obtain psychological and psychiatric opinion as part of the child abuse assessment.

Unrealistic Expectations

A parent may:

Inconsistent care

A child may be indulged and abused by turns and simply not know whether they are loved.  They are unable to work out how they will be received from moment to moment, their lives contain no rhythm, routine, stability or predictability. 

5.0 Sexual Abuse

Full sexual intercourse is only one form of sexual abuse.  Others are fondling, masturbation, digital penetration, oral or genital contact, photographing or filming for pornographic purposes, procuring and knowingly committing any form of sexual abuse to occur.

Sexual abuse may take the form of stranger or familial abuse.  Some children are abused by complete strangers but the vast majority of reported cases of sexual abuse concern perpetrators who are well known to a child such as members of the child's immediate and extended family.

Sometimes the perpetrator may hold positions of trust with respect to the child such as teacher, babysitter, care worker, neighbours or family friends. 

The vast majority of perpetrators are male, often fathers, stepfathers, uncles, older brothers or cousins.  Sometimes women do abuse children sexually or co-operate with the male in perpetrating such abuse.

Boys are just as likely to be sexually abused as girls. Babies and toddlers may be sexually abused as well as older children.

Abuse within a family is rarely an isolated event. It sometimes lasts for months and years and may involve more than one child. Abuse usually escalates from caressing and fondling, which the child may welcome initially, to mutual masturbation and penetration.

Diagnosis of sexual abuse should not rely on physical signs alone as a substantial proportion of sexually abused children will have no abnormal physical signs. It should be remembered that physical signs of sexual abuse may heal within hours or days. 

Concern should be felt and a forensic medical examination undertaken, when the following are present:

The psychological indicators sometimes linked to child sexual abuse include:

The patterns of behaviour in particular children will depend on the age, sex and stage of development of the child:

N.B. Many of these symptoms are also associated with other forms of childhood disturbance and should not in themselves be seen as diagnostic.

It is not possible to identify a personality type who may abuse a child sexually, although a remarkable number of perpetrators have suffered from sexual abuse themselves.  Nor is it possible to identify a particular type of family in which a child may be at risk of sexual abuse.  There is no substitute for careful observation of and communication with the child and family in question.  It is never safe to assume that because a girl in a family has been abused that a boy is unlikely to be harmed, or vice versa. The following are some possible characteristics (from research and experience) of families where sexual abuse has taken place:

A disclosure by a child should always be taken seriously and be thoroughly investigated.

6.0 Common Family Characteristics

Certain family and social characteristics have been frequently noted in cases of child abuse.

Again, their presence does not prove that an injury was non-accidental, nor does the absence of any of these characteristics mean there will be no cause for concern. The presence of a number of the following factors, however, will almost certainly indicate that the family is under great stress and in need of help, whether an injury has occurred or not. The following are indicators for the need to be alert:

The parents

The child

Family circumstances

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