Child abuse - physical

Definition

The physical signs of child abuse were originally called "Battered Child Syndrome" -- represented by multiple fractures in different states of healing. The fractures occur at different times in children too young to have received the fractures as a result of an accident.

The definition of child abuse has expanded significantly. In addition to multiple fractures with different ages, what is now called "physical child abuse" or "non-accidental child trauma" also contains numerous other signs of inflicted injury.

See also:

• Child sexual abuse
• Child psychological abuse and neglect

Causes, incidence, and risk factors

Abuse tends to occur at moments of greatest stress, when the perpetrator strikes out in anger at the child. Many perpetrators were themselves abused as children and they often don't realize that abuse is not appropriate discipline. Abusers also frequently have poor impulse control, which prevents them from thinking through the consequences of their actions.

Because adults are so much stronger and bigger than children, the abused child can be severely injured or killed unintentionally. For example, shaking an infant, especially if the head hits something, even against a soft object like a mattress or pillow, can cause bleeding over the brain (subdural hematoma). This can cause permanent brain damage or death. (See shaken baby syndrome.)

Unfortunately, the rate of child abuse is fairly high. The most common form is neglect. Child abuse accounts for at least 1,400 deaths in children each year.

The major risk factors related to adult abusers include poverty, lack of education, single parenthood, and alcoholism or other drug abuse.

Symptoms

• Adult brings an injured child to an emergency room with an improbable explanation of the cause of the injury, or the injury is not recent
• Unusual and unexplained bone fractures
• Bruise marks shaped like hands, fingers, or objects (such as a belt), or unexplained bruises in areas where normal childhood activities would not usually result in bruising
• Specific patterns of scalding, seen when a child is immersed in hot water as a punishment -- particularly "glove" or "sock" burn patterns
• Burns from an electric stove, radiator, heater or other hot objects, usually seen on the child's hands, arms or buttocks
• Cigarette burns on exposed areas or the genitals
• Black eyes in an infant or a similar, unexplained injury in a child
• Human bite marks
• Lash marks
• Choke marks around neck
• Circular marks around wrists or ankles (indicating twisting or tying up)
• Separated sutures
• Bulging fontanelle
• Evidence of unexplained abdominal injury (such as bruised or ruptured intestines due to punching)
• Unexplained unconsciousness in infant

Signs and tests

Typical injuries in abused children include:

• Bleeding in the back of the eye, seen with shaken baby syndrome or a direct blow to the head
• Internal damage, such as bleeding or rupture of an organ from blunt trauma
• Any fracture in an infant too young to walk or crawl
• Evidence of fractures at the tip of long bones or spiral-type fractures that result from twisting
• Fractured ribs, specially in the back
• Evidence of skull fracture (multiple fractures of different ages may be present)
• Subdural hematoma (collection of blood in the brain) without plausible explanation
• Multiple bruises of different ages, especially in unusual areas of the body (e.g., not the shins) or in patterns suggesting choking, twisting, or severe beating with objects or hands
• Other unusual skin damage, including burns or burn scars

• Bone x-ray -- a skeletal survey is done whenever physical abuse is suspected. All the child's bones, including the skull, are x-rayed to look for undetected fractures or old, healing fractures.
• MRI or CT scan of the head or abdomen are done if there is a skull fracture, bleeding in the eye, unexplained vomiting, severe bruising of the face, skull or abdomen, or unexplained neurological symptoms, headaches, or loss of consciousness.

The following medical conditions can mimic abuse:

• Osteogenesis imperfecta - almost all children with this condition have an abnormal (blue) coloring of the whites of the eyes. These children may have spontaneous fractures or break bones after normal accidents that would not harm the bones of a normal child.
• Undetected bleeding disorders such as hemophilia, Von Willebrand's disease, or liver disease can lead to abnormal bruising patterns. The doctor can test for these disorders.
• Unusual bruising and scarring patterns can also be caused by folk medicine or Oriental Medicine practices such as coin rubbing, cupping, and moxabustion (burning herbs on the skin over acupuncture points). The doctor should always ask about alternative healing practices.

Treatment

The specific physical injuries are treated as appropriate.

Counseling or an intervention of some type for the parents is mandatory. In some cases, the child may be temporarily or permanently removed from the home to prevent further danger. Life-threatening abuse, or abuse resulting in permanent damage to the infant or child, may result in legal action.

Counseling, including play therapy, is also necessary for abused children over age 2. Failure to help the child deal with the fear and pain resulting from abuse by adults, who should be trusted figures, can lead to significant psychological problems, such as post traumatic stress disorder (PTSD).

All states require that you report any known or suspected child abuse. Call the police and Child Protection Services.

Decisions about placing the child with an outside caregiver or returning the child to the home usually are made by the appropriate government agency through the court system. The structure of these agencies varies from state to state.

Support Groups

Support groups are available for survivors of abuse and for abusive parents who want to get help. See the resource page for contact information.

Expectations (prognosis)

The child's physical recovery depends on the severity of the injuries. Psychological recovery depends on the results of psychotherapy and whether the child can develop trusting relationships with adult caretakers.

The authorities will determine whether the abuser receives psychiatric help, such as parenting training and impulse/anger management training.

Child protection agencies generally make every effort to reunite families when possible.

Complications

Physical abuse of a child can lead to severe brain damage, disfigurement, blindness, crippling, and death. Abused individuals may carry emotional scars for a lifetime.

Children can be removed permanently from the parents' custody if the parents are the perpetrators and the cause is sufficient to warrant termination of parental rights. However, this experience itself can result in significant psychological problems due to feelings of rejection, or if the placement does not result in a strong, long-term attachment to new caregivers.

Calling your health care provider

Call your health care provider, Child Protective Services, or local police if you suspect or know that someone is being abused.

Prevention

Recognize the warning signs of potential abuse. These include when the caregiver:

• has previously abused a child
• fails to maintain the child's proper hygiene or care
• appears to lack love or concern
• has alcohol or drug problems
• has emotional problems or mental illness
• was abused as a child
• has high stress factors, including poverty

Illustrations

Fracture types (1)

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