eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect, Physical Abuse

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing

Updated: Dec 12, 2008

Introduction

Background

Physical abuse, a subset of child abuse, is defined in various ways by different states. However, common to all definitions is the presence of an injury that the child sustains at the hands of his or her caregiver. These injuries are also referred to as inflicted or nonaccidental injuries. Some states use broad definitions that encompass a wide range of injuries; other states use more narrow definitions that include specific signs and symptoms. Physical abuse can produce various injuries and injury patterns in children. This article focuses on several common examples of inflicted injury dealing with the skeleton (eg, fractures), skin (eg, burns, bruises), and CNS (eg, subdural hematoma [SDH], abusive head trauma [AHT], shaken baby syndrome [SBS]/shaking-impact syndrome).

Definitions of physical abuse

The federally funded Third National Incidence Study (NIS-3) defines physical abuse as a form of maltreatment in which an injury is inflicted on the child by a caregiver via various nonaccidental means, including hitting with a hand, stick, strap, or other object; punching; kicking; shaking; throwing; burning; stabbing; or choking to the extent that demonstrable harm results.¹

The advantage to a narrow definition is that it objectively states what is and is not physical abuse; however, such a clear delineation of circumstances likely fails to identify all possible cases of physical abuse (eg, pulling the child's hair, biting the child's skin). Definitions may also attempt to characterize the seriousness of injury; however, characterization is difficult because injuries vary greatly from mild redness on the buttocks that fades over several hours to injuries so severe that the child dies. Recent medical definitions focus more on the effect of the injury on the child and less on the perceived intention of the caregiver because the child presents with an injury in need of care to the health care provider.

Additionally, newer definitions also consider the sociocultural context in which the injury occurs; folk healing practices may cause the appearance of nonaccidental injury to the child. Finally, the effect of the physical abuse may not be limited to just the immediate injury findings. The National Center on Child Abuse and Neglect (NCCAN) estimated that 37% of children with maltreatment injuries developed a disability or special need, directly from the abusive actions or omissions of the child's caregivers.² Furthermore, NCCAN estimated that incidence of disabilities caused by or likely to have been caused by maltreatment was 147 per 1000 maltreated children.

Multifactorial nature of physical abuse

No one single cause has been identified that explains the occurrence of all cases of physical abuse. The multifactorial nature of physical abuse requires a more comprehensive amalgam of models and conceptual frameworks to account for the heterogeneous set of cases classified as physical abuse.

Circumstances that may give rise to the occurrence of a child's injury via physically abusive actions have been organized into a typology having the following 5 subtypes: (1) caregiver's angry and uncontrolled disciplinary response to actual or perceived misconduct of the child; (2) caregiver's psychological impairment, which causes resentment and rejection of the child by the caregiver and a perception of the child as different and provocative; (3) child left in care of a baby-sitter who is abusive; (4) caregiver's use of substances that disinhibit behavior; and (5) caregiver's entanglement in a domestic violence situation.

This typology describes commonly observed circumstances that may result in nonaccidental injury to children; however, it does not shed light on why the circumstance leads to a child's injury.

Ecological model of human development and interaction

The ecological model of human development and interaction is generally regarded as an ideal conceptual framework from which to approach the complex interactions among the caregiver, child, family, social situation, and cultural values leading to the nonaccidental injury or physical abuse of the child.

Ecological model for understanding violence.

Environmental stress and caregiver frustration

Helfer builds on this ecological viewpoint and states that physical maltreatment arises when a caregiver and child interact around an event, in a given environment, with the end result being injury to the child.³ Viewing maltreatment in this way allows consideration of the factors that the caregiver, child, and environment contribute to placing the child at risk for injury. The caregiver is viewed as having a personal developmental history, personality style, psychological functioning, and coping strategies. The caregiver often possesses expectations of the child, and a level of ability to nurture the child's development that meets the child's developmental and caregiving needs.

The child may have certain characteristics that make providing care more complex; however, caution must be used in considering the child's contribution to the abusive interactions because the child needs safe, nurturing parenting regardless of any characteristics that he or she may possess. Specific factors that may place the child at higher risk for physical maltreatment include prematurity, poor bonding with caregiver, medical fragility, various special needs (attention deficit hyperactivity disorder), and the child being perceived as different (owing to physical, developmental, and/or behavioral/emotional abnormalities) or difficult, based on temperament style.

Finally, the environment may contain stressors that may make the caregiving less than ideal and may overextend the coping abilities of the caregiver. While exploring the role of environmental stress and caregiver frustration in the occurrence of child abuse, Straus and Kantor found a complex interaction between the amount of stress present in the family setting and the response of the caregivers.⁴ Not all stressed caregivers responded by inflicting harm on the children in the environment.

Straus and Kantor concluded that human beings have a capacity for acting violently both in and outside the family setting. Physical abuse can result if a specific home situation arises that has a relatively high degree of stress and a baseline amount of violence within it (eg, spanking the children, pushing or slapping a spouse). Thus, risk of child abuse is related to the response of caregivers whose caregiving environment has a certain amount of overall risk for violent behavior. The caregivers' level of social connectedness to nonrelatives seemed to have a role to play in the children's risk for maltreatment. Caregivers under high degrees of stress who did not participate in clubs, unions, and other organizations (ie, socially isolated) had higher rates of abusing children than those who were not as socially isolated. However, children whose caregivers had many family members living nearby did not achieve the same protective effect, as did the nonfamilial social connectedness group.

Domestic violence, intimate partner violence, corporal punishment, and child maltreatment

The relationship of domestic violence or intimate partner violence (IPV) and child maltreatment is receiving increasing attention. Each year, between 3.3 and 10 million children witness episodes of family violence; 30-59% of mothers of abused children are victims of domestic violence or intimate partner violence. Additionally, children whose mothers are victims of domestic violence or intimate partner violence are 6-15 times more likely to be maltreated compared to children living in families in which their mothers are not being battered. The American Academy of Pediatrics (AAP) recommends that pediatricians assess for the presence of domestic violence and intimate partner violence in the child's family and observes that intervening on behalf of the victimized parent (typically the child's mother) may be an effective child-abuse prevention strategy.⁵

Overlap of child maltreatment and domestic violence.

No credible evidence in medical literature supports the continued use of corporal punishment; spanking is less effective than time out or removal of privileges for decreasing undesired behavior in children. Discipline, however, is a necessary component for child rearing, and appropriate discipline aims for limit setting, teaching right from wrong, assisting in decision making, and helping the child develop a sense of self-control.

When physical force is used as a discipline technique (as in corporal punishment), the concern arises that if the misconduct continues even after corporal punishment is applied, the caregiver then may become angry and frustrated and reapply the physical force. As the physical force is reapplied while the caregiver is becoming increasingly angry, the potential emerges for the caregiver to lose control and injure the child. Regardless of whether injuring the child was the intended outcome of the corporal punishment, the end result experienced by the injured child is that he or she has been hurt.

Caregivers who use corporal punishment are often angry, irritable, depressed, fatigued, and stressed. They apply the punishment at a time that they "have lost it," and caregivers frequently express remorse and agitation while punishing their children. To avoid this risk of harming the child and in order to model nonviolent behavior for children, many health care professionals advocate child discipline via consistent, nonphysical force based approaches such as time out, loss of privileges, expressions of parental disappointment, and grounding. Approximately one half of US pediatricians report being opposed generally to the use of corporal punishment; about one third are completely opposed to its use (about three fourths of the pediatricians reported having been spanked when they were children).

Pathophysiology

Each form of injury sustained by a child as a result of physical abuse has its own set of biomechanics and pathophysiology. This article looks specifically at the mechanisms of injury for skeletal injury, burns, bruising, and CNS injury observed in AHT, SBS, and shaking-impact syndrome.

Skeletal fractures are caused by the application of force to the bone. The child's immature skeleton is characterized by more porous bone than in the mature bone. As a result, the less dense porous bone is more at risk for compression injury and accounts for the bending and buckling injuries observed with green stick and buckle injuries. The periosteum (the fibrous membrane that covers the bone) is thicker and more easily elevated off of the bone in children. The child's joint capsule and ligaments are strong and relatively more resistant to stress than the bone and cartilage, which accounts for less joint dislocations in childhood. Finally, bone healing is more rapid in children than in adults.

Types of fractures

Several types of fractures occur in childhood and may be observed in physical abuse. Diaphyseal fractures are breaks in the mid shaft of the long bones. These fractures may be transverse if the force is applied perpendicular to the long axis of the bone; spiral if the force applied is rotational in nature. Metaphyseal fractures are microfractures through the immature part of the bone edge and often appear like chips or corner fractures on radiographs. The metaphysis is an area of rapid bone turnover in the growing infant and toddler. Rapid acceleration and deceleration forces to the extremity generate fractures.

Skull bones may be fractured as a result of direct impact to the head with a solid surface or object. The skull bones are different than long bones in that they develop within a membrane and not from cartilage as do the long bones. Fractures of the skull bones occur, and the healing mechanism observed is different than that observed in the long bones. Rib fractures may be observed in physical abuse as well. Rib fractures occur as a result of direct blows to the chest and via anteroposterior compression. Most abusive rib fractures are posterior, adjacent to the vertebral body, with the rib levering over the transverse process of the vertebra.

Bone healing and dating of injuries

Fractured long bones and ribs heal in a predictable manner, which is divided into the following 4 stages: initial healing, soft callus, hard callus, and remodeling. Orthopedic aspects of bone healing are described in Fractures, Forearm. In young children, bone healing tends to occur more rapidly than in older children and adults. This healing process permits some level of dating of injuries and allows the health care professional to distinguish new and relatively older fractures in the same child.

Dating of injuries is particularly important in the evaluation of physical abuse, because it may assist investigators in determining who had access to the child in the period of time that the injury is estimated to have occurred. Metaphyseal fractures are generally harder to date because of the relative lack of disruption in the periosteum at the time of the fracture. Skull fractures heal differently than do long bones because of their intramembranous nature; they do not heal with a large amount of callus formation and are more difficult to date. The skills and advice of an experienced pediatric radiologist should be consulted if dating of injuries becomes central to the maltreatment investigation.

Burns

Burns arise from the application of heat energy to the child's skin. Various sources such as hot liquids (scalds), hot objects (contact or dry), flame (flash), chemicals, and electricity can generate heat. Three concentric zones of affected tissues have been identified. Coagulation is the most direct contact with the heat source in which the skin undergoes immediate coagulation necrosis as the proteins denature, and no cellular repair is possible. Stasis involves less heat energy exposure than with coagulation, and these cells, though injured, have some potential for repair. Hyperemia is the least direct injury, and these cells have the greatest potential for repair.

Human skin is composed of 3 layers, the epidermis, dermis, and subcutaneous tissue. Burns are classified clinically depending on the depth of the injury and the involvement of the various skin layers. Superficial burns, which injure only the uppermost tissue of the epidermis, present as red, painful areas without blisters. Complete healing is expected from superficial burns. Deeper burns that extend through the epidermis into the upper levels of the dermis are referred to as partial thickness burns and present as painful blistering areas.

Healing varies with partial thickness burns with varying degrees of scarring depending on the level of tissue that is damaged. Finally, the deepest burns, full thickness burns, extend past the epidermis and dermis and involve the subcutaneous tissue. These burns essentially have destroyed the overlying skin, blood vessels, and associated nerves and present as white insensitive areas because of this destruction. A high degree of scarring and disfigurement result from full thickness burns.

Bruising

Bruising occurs when blunt mechanical force is applied to the child's skin to such a degree that capillaries (and potentially larger vessels) become disrupted resulting in the leakage of blood into the subcutaneous tissue. The amount of blood and size and location of the involved area account for the appearance of the bruise. If force is applied via an object, the bruise may reflect the shape and geometry of the object.

In general, a bruise progresses through a series of colors beginning with deep red, blue, or purple, then changes to a deep blue, then greenish, and, finally, resolves with a yellowish brown color. The various colors emanate from the breakdown of the extravascular blood into the components of hemoglobin. As the extravascular blood organizes itself and is resorbed, certain patterns of color change are expected; however, caution is advised because no clearly predictable chronology can be relied on with absolute certainty. Physicians should be cautious in offering dating information and, at most, only should suggest broad time ranges based on the clinical appearance and stages of healing of the bruise.

CNS trauma

CNS trauma is among the most serious forms of injury that is observed in the context of physical abuse. CNS trauma may result in intracranial hemorrhage, including (1) epidural hemorrhage, which is bleeding into the space between inner skull bone surface and the dura, frequently due to a direct injury to the middle meningeal artery; (2) subdural hemorrhage, which is bleeding into the space between the inner surface of the dura and arachnoid membranes, typically caused by sheering of the bridging vessels that go from the brain surface to the dura; and (3) subarachnoid hemorrhage, which is bleeding into the space between the inner surface of the arachnoid and the brain surface. Other CNS injuries may include contusions (ie, direct injury to the brain tissue) and intraparenchymal bleeding (ie, bleeding directly into substance of the brain).

AHT, SBS, and shaking-impact syndrome

Discussing CNS injury and physical abuse inevitably leads to a discussion of SBS or shaking-impact syndrome, which is now referred to as AHT. SBS (originally referred to as whiplash syndrome) describes a clinical constellation of findings classically described as subdural hematoma, retinal hemorrhage (found in 65-95% of cases), and skeletal fractures, such as metaphyseal fractures and posterior rib fractures (found in 30-70% of cases) sustained while the child is shaken violently back and forth. AHT represents a significant injury pattern in the realm of child maltreatment; although it is associated with the findings listed above, the core injury is to the brain cells themselves, resulting from the application of forces to the child's delicate and developing brain tissue.

AHT has been extended to include cases where the child's head is impacted against a surface, either soft or hard, and may be called either AHT or shaking-impact syndrome. Diffuse, serious brain injuries result from forces that result in rotation of the brain about its center of gravity. Such forces exceed those generated in normal childcare activities and are different from the low velocity translational forces (straight-line movement) that commonly occur in household falls. Immense angular deceleration forces may be generated with sudden striking of the child's head against a surface; these forces act on the brain tissue and cerebral vessels and generate the deleterious effect, which is not specifically from the contact forces applied to the skull.

Frequency

United States

In 2006, approximately 3.3 million reports involving 6 million children were made to Child Protective Services (CPS) agencies. Of these, 61.7% were accepted as needing further investigation, and, once evaluated, the investigations concluded that child abuse and neglect had affected approximately 905,000 children, with 16% of this total representing cases of substantiated physical abuse. The most common form of substantiated abuse in 2006 was child neglect, which accounted for 64.1% of cases, followed by child sexual abuse (8.8% of cases) and emotional maltreatment (6.6% of cases).  

The Third National Incidence Study (NIS-3) reported that, of the approximately 1.5 million estimated annual cases of child abuse, approximately 380,000 cases were identified as physical abuse, which constituted an annual incidence of 5.7 per 1000 children.¹ The incidence of physical abuse in the 1993 NIS-3 (5.7 per 1000 children) rose by 33% from the 1986 Second National Incidence Study (NIS-2) (4.3 per 1000 children). In various clinical series, skeletal fractures are observed in approximately 30% of the children, burns are observed in 9-10%, bruises are quite common and are present in approximately 40% of child maltreatment cases, and inflicted CNS injury is observed in 24% of children treated for head injury.

The Fourth National Incidence Study (NIS-4) is currently underway and is mandated by the US Congress in the Keeping Children and Families Safe Act of 2003 (P.L. 108-36); once completed, it will provide the most up-to-date epidemiologic incidence data.⁶  The NIS methodology views maltreated children who are investigated by CPS agencies as representing only the "tip of the iceberg;" thus, children investigated by CPS are included along with maltreated children who are identified by professionals in a wide range of agencies in representative communities. The NIS-4 uses data gathered from a nationally representative sample of 122 counties. CPS agencies in these counties provide data about all children in cases they accept for investigation during 1 of 2 reference periods (September 4, 2005 through December 3, 2005, or February 4, 2006 through May 3, 2006).

Additionally, professionals in these same counties serve as NIS-4 sentinels and report data about maltreated children identified by the following organizations: elementary and secondary public schools; public health departments; public housing authorities; short-stay general and children's hospitals; state, county, and municipal police/sheriff departments; licensed daycare centers; juvenile probation departments; voluntary social services and mental health agencies; shelters for runaway and homeless youth; and shelters for victims of domestic violence. The final report for the NIS-4 is expected to be available in 2009.

Finkelhor and Jones have analyzed trends in reporting and substantiation rates for child abuse and neglect from the 1990s through 2006 and have identified a decline in the number of substantiated cases of physical abuse.⁷ According to their most recent analysis, the incidence of substantiated physical abuse cases declined 48% from 1992-2006. Between 2005 and 2006, incidence declined by 3%. Cases of child sexual abuse have also declined substantially with a 53% decrease in the number of substantiated cases of sexual abuse observed from 1992-2006. However, child neglect, the most common form of child maltreatment, has not declined; from 2005-2006, substantiated cases of child neglect increased by 2%.

US child maltreatment trends.

Mortality/Morbidity

Mortality

According to the 1993 NIS-3 study, an estimated 1500 children were known to have died as a result of maltreatment.¹ According to Prevent Child Abuse America's National Center on Child Abuse Prevention Research, in 2006 an estimated 1,530 were known to have died as a result of child maltreatment, which is an average of 4 children each day of the year.⁸ Children aged 0-3 years accounted for 78% of the child abuse and neglect fatalities, with infants younger than 1 year accounting for 44.2% of these maltreatment-related fatalities. When looking at the types of maltreatment that accounted for the fatalities, the breakdown is as follows:

• Child neglect - 43% 
• Multiple forms of maltreatment - 31.4%
• Physical abuse - 22.4% 
• Psychological abuse - 2.9%
• Child sexual abuse - 0.3%

The estimated death rate for child abuse and neglect in the United States is 2.04 per 100,000 children.

Morbidity

Different forms of injury have different risks. For example, CNS injury in younger children is particularly serious. Bruises may be superficial or harbingers of more serious deeper injury. Burns observed in child maltreatment cases tend to be highly severe. Finally, skeletal injuries may be isolated or multiple in nature and may be associated with other injuries. DiScala and colleagues conducted a 10-year retrospective of medical records in the National Pediatric Trauma Registry (NPTR) from 1988-1997; it compared hospitalized, injured children younger than 5 years to determine differences between inflicted (n= 1,997) and accidental injuries (n= 16,831).⁹

They found that, compared with children who had accidental injury, children who were abused tended to be younger (12.8 mo vs 25.5 mo), were mainly injured by battering (53%) and shaking (10.3%), and were more likely to have a preinjury medical history of a medical problem or condition. The unintentionally injured children were mainly injured by falls (58.4%) and motor vehicles (37.1%)

National Pediatric Trauma Group registry findings.

Looking at potential long-term impacts on health and well being, Felitti et al explored the connection between exposure to childhood abuse and the connection between household dysfunction to subsequent health risks and the development of illness in adulthood in a series of studies referred to as the Adverse Childhood Experiences (ACE) studies.¹⁰ Of 13,494 adults who completed a standard medical evaluation in 1995-1996, 9,508 completed a survey questionnaire that asked about their own childhood abuse and exposure to household dysfunction; the investigators then made correlations to risk factors and disease conditions.

In order to assess exposure to child abuse and neglect, the ACE questionnaire asked about categories of child maltreatment, specifically psychological, physical, and sexual maltreatment. When asking about physical abuse, the questionnaire asked the patients if a parent or other adult in the household had (1) often or very often pushed, grabbed, shoved, or slapped them or (2) often or very often hit them so hard that marks or other injuries resulted.

In order to assess exposure to household dysfunction, the ACE questionnaire asked questions by category of dysfunction, such as having a household member who had problems with substance abuse (eg, problem drinker, drug user), mental illness (eg, psychiatric problem), criminal behavior in household (eg, incarceration) or having a mother who was treated violently. In assessing if their mother was treated violently when the patient was a child, respondents were asked if their mother or step-mother was (1) sometimes or very often pushed, grabbed, slapped, bitten, hit with a fist, or hit with something hard or had something thrown at her or (2) was ever repeatedly hit for at least a few minutes or threatened with or hurt by a knife or gun.

In addition to the questionnaire information, the standardized medical examination of the adults assessed risk factors and actual disease conditions. The risk factors included smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, any drug abuse, a high lifetime number of sexual partners, and a history of sexually transmitted disease (STD). The disease conditions included ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, and skeletal fractures. Once all of the data was collected and analyzed, Felitti et al found that the most prevalent ACE was substance abuse (25.6%), the least prevalent ACE was criminal behavior (3.4%), and the prevalence of physical abuse was 10.8% and the prevalence of the mother being treated violently was 12.5%.

Overall, 52% of the respondents had one or more ACEs and 6.2% had 4 or more ACEs. The following were findings in respondents who experienced 4 or more ACEs compared with those who had none:

• Risk of alcoholism, drug abuse, depression, and suicide attempt increased 4-12 fold
• Rates of smoking, poor self-rated health, and high number of sexual partners and STDs increased 2-4 fold
• Physical inactivity and severe obesity increased 1.4-1.6 fold

Adverse child experiences pyramid.

Race

No significant difference in incidence of physical abuse was noted based on race; this is a consistent finding in both the 1993 NIS-3 as well as the 1986 NIS-2. In Child Maltreatment 2006, racial information for 85,324 cases of physical abuse and breakdown is as follows black (12.9%), American Indian/Alaskan Native (6.4%), Asian (14.6%), native Hawaiian/Pacific Islander (11.4%), white (9.8%), multiple racial affiliations (8.1%), Hispanic (9.6%), and unknown/missing information (12.9%).⁷

Sex

Incidence of physical abuse is nearly identical between male and female children and is not statistically different (5.8 cases per 1000 males compared with 5.6 cases per 1000 females). However, boys are at higher risk for serious injury. A specific gender breakdown for physical abuse was not provided in Child Maltreatment 2006, but overall for 882,537 cases of child maltreatment, including all forms of child abuse and neglect in 2006, 48.2% of the substantiated cases were in boys and 51.5% of cases were in girls.

Age

In the NIS-3, the comparison of physical abuse between age groups revealed only one significant difference: children aged 12-14 years had a specific incidence of 7.4 cases per 1000 children versus children younger than 2 years who had an incidence of 3.2 per 1000. The age-specific incidence estimates for the other groups were only marginally different when compared with each other. The fairly low incidence rates for children younger than 2 years may reflect a detection problem; because younger than school-aged children are less observable to community professionals, their abuse may avoid detection. Inflicted brain injuries in infants tend to be particularly severe. In Child Maltreatment 2006, the age break for 142,041 cases of substantiated physical abuse was as follows: age younger than 1 year (10%), age 1-3 years (13.2%), age 4-7 years (23%), age 8-11 years (20.6%), age 12-15 years (24.2%), and age 16 years and older (8.4%).

Clinical

History

Understanding the developmental level and abilities of the child is essential in determining if the history provided by the parent or caregiver is a possible or plausible explanation for the child's injury. Once the full extent of the injury is determined based on physical examination and laboratory workup, the health care provider can further assess the plausibility of the explanation offered by the parent or caregiver. A history that is implausible based on what a child at that level is capable of doing should raise a high degree of concern for possible maltreatment.

• Whenever a child is injured, a complete history of the circumstances surrounding the injury is essential. Basic questions include the following:
  • What was the date and time of the injury and when was it first noted?
  • Where did the injury occur?
  • Who witnessed the injury?
  • What was happening prior to the injury?
  • What did the child do after the injury?
  • What did the caregiver do after the injury?
  • How long after the injury did the caregiver wait until seeking care for the child?
• The past medical history should be explored for general health and previous trauma and hospitalizations, as well as for the source of health care and developmental and social aspects of the child's life. The following histories raise concerns for possible physical abuse:
  • Inconsistent details that change over time are offered.
  • Caregivers give implausible details not congruent with the trauma observed on examination.
  • Caregivers describe minor trauma, but the child displays major injury on examination.
  • No history of trauma is offered (so called "magical injuries").
  • Injury is described as self-inflicted and is not compatible with the age or developmental abilities of the child.
  • Caregivers demonstrate a significant delay in seeking treatment for the child.
  • Serious injury is blamed on a younger sibling/playmate. In cases of maltreatment, the history is often inaccurate and misleading.
  • Caregiver frequently changes health care facilities, pediatricians, or emergency departments.

Physical

Physical examination of the child with an injury obviously is important, and the order of the complete examination is determined by the presenting condition of the child. Children with less severe injuries in stable condition can have the injured area examined last, since that area is most likely to be uncomfortable. Severely injured children in critical condition require life saving measures first, following the standards of care for trauma life-support; other components of the examination follow from that point.

• Because physical abuse is often an ongoing pattern of unsafe care, performing a thorough head-to-toe examination is essential in order to find other areas of either current or previous injury. Physical indicators that should raise suspicion for maltreatment include the following:
  • Injury pattern inconsistent with the history provided
  • Multiple injuries/multiple types of injuries
  • Injuries at various stages of healing
  • Poor hygiene
  • Presence of pathognomonic injuries including loop marks, forced immersion burn pattern, and classic shaken baby findings of subdural hematoma, retina hemorrhage, and skeletal injuries
• Skeletal injuries in children younger than 2 years may not be obvious; therefore, a skeletal survey typically is recommended (see Workup) for the components of the skeletal survey. Fractures that raise a high degree of suspicion for inflicted injury include the following:
  • Metaphyseal fractures
  • Multiple, bilateral, differently aged posterior rib and scapular fractures
  • Multiple and complex skull fractures
  • Spinous process fractures
  • Spiral fractures in nonwalking infants
• Burn patterns that may suggest physical maltreatment include the following:
  • Patterned burns
  • Classic forced immersion burn pattern with sharp stocking and glove demarcation and sparing of flexed protected areas
  • Splash/spill burn patterns not consistent with history or developmental level
  • Cigarette burns
• Additionally, other concerning aspects to the burn physical examination that should raise the concern for possible abuse include the following:
  • Incompatible history and physical examination
  • Incompatible burn and developmental level
  • Bilateral or mirror image burns
  • Localized burns to genitals, buttocks, and perineum (especially at toilet training stage)
  • Evidence for excessive delay in seeking treatment, and the presence of other forms of injury
• Bruising over bony prominences are common in childhood, but patterns of bruising that raise the concern of possible abuse include the following:
  • Involvement of multiple areas of the body beyond bony prominences
  • Bruises at many stages of healing
  • Bruises in nonambulatory child
  • Markings resembling objects, grab marks, slap marks, human bites, and loop marks
• A child with CNS injury often is seriously ill, presenting in a life-threatening condition with seizures and respiratory arrest.
  • For serious life-threatening injury, no data support the existence of a lucid period between the time of injury and the onset of symptoms; rather, for acute subdural hematoma with severe neurologic sequela, clinical deterioration would be expected immediately around the time of injury.
  • Finally, traumatic acute subdural hematomas, especially those that lead to the death of child, do not occur in a subclinical or insidious manner in an otherwise healthy infant.

Causes

No one single cause has been identified that explains the occurrence of all cases of physical abuse.

Differential Diagnoses

Child Abuse & Neglect: Physical Abuse

Other Problems to Be Considered

• Determining whether an injury was inflicted by a caregiver or caused by accidental means is extremely important because the treatment plan and well being of the child and family are at stake. Many medical conditions may mimic the findings possibly observed in physical abuse. One would expect that the clinical history surrounding the presentation and physical examination would be consistent and indicate the presence of such a noninflicted etiology. Differential diagnoses should be worked through carefully in cases of suspected inflicted injury so that suspected physical abuse can be diagnosed confidently and caregivers are not inappropriately accused of abuse.
• Skeletal fractures: For skeletal fractures, the differential diagnoses include normal variants of bone structure (may appear as suspicious findings on radiographs), congenital syphilis (leads to periosteal elevation), rickets (cause bone fragility), and osteogenesis imperfecta (OI). OI is frequently raised as a possibility in cases of an unexplained fracture and possible physical abuse. Four types of OI are recognized, as follows:
  • Type I is the most common form, has autosomal dominant inheritance, and is responsible for 80% of cases. Type I may easily be confused with maltreatment. Other major findings of type I include mildly to moderately severe bone fragility with occasional fractures at birth, easy bruising, short stature, and blue sclera. Type I OI may be associated with family history of hearing impairment.
  • Type II is a perinatal lethal form. Death typically occurs by age 1 month, with multiple fractures at birth.
  • Type III is rare and is easily distinguished from maltreatment because of severe bone fragility and osteopenia, triangular facies, ligamentous laxity, skeletal deformity, and the appearance of teeth.
  • Type IV is the most difficult to distinguish from maltreatment because bones may appear normal when the first fracture develops but are usually characterized by mild-to-moderate bone fragility, osteopenia, wormian bones, birth fractures in approximately one third of cases, and normal sclerae. Genetic consultation is necessary to pursue a more detailed workup for OI and the characterization of the collagen disorder.
• Burns: The differential diagnoses for lesions that appear as burns includes impetigo (may appear circular and be confused with cigarette burns), phytophotodermatitis (reddened areas and erosions that result from sun exposure of skin that has psoralen residue), dermatitis herpetiformis (immunobullous skin condition characterized by blisters that may erode), and folk-healing practices such as coining (rubbing of coin or spoon repetitively over the skin), cupping (application of heated cup over skin with resultant vacuum action as it cools), and moxibustion (application of heated incense to skin). As the physician works through each of these diagnostic possibilities, the physician should look for a history supporting this diagnosis over a diagnosis of suspected physical abuse.
• Bruises: For bruises, the differential diagnoses include Mongolian spots (collection of melanocytes producing a bluish color present at birth in 80% of black children), hemangiomas (overgrowth of capillaries), eczema, phytophotodermatitis, erythema multiforme (multi-shaped red lesions believed to be a sensitivity reaction), idiopathic thrombocytopenic purpura (ITP), easy bruising observed with bleeding diathesis, malignancy, Ehlers-Danlos syndrome, OI type I, and previously described folk healing practices (eg, coining, cupping).
• CNS injuries: The differential diagnoses for the various findings observed in CNS injuries include various serious disorders such as infections like meningitis, neurologic conditions that have seizures as a component, and ingestions that may simulate the serious clinical features of CNS injury.
• Abusive head trauma (AHT)/shaken baby syndrome (SBS): In considering the differential diagnoses for the findings in AHT/SBS, the differential diagnosis subdural hematoma and retinal hemorrhages needs to be considered. For subdural hematoma, the differential diagnoses includes accidental trauma, coagulation disorders, vascular malformations, the rare amino acid inborn error of metabolism glutaric aciduria type I (associated with acute encephalopathy and chronic subdural hematoma), and the folk healing practice caida di mollera, in which a child with a sunken fontanel is inverted, held upside down by the ankles, and shaken.
• Retinal hemorrhages: For retinal hemorrhages, the differential diagnoses includes vasculitis, vascular obstruction, and toxic febrile states associated with serious infection. Again, in working through a differential diagnoses, the workup should reveal history and physical examination findings supportive of such a diagnosis over physical abuse.

Workup

Laboratory Studies

• History and the physical findings determine which laboratory and diagnostic imaging studies are necessary.
• If a bleeding problem is suspected, a bleeding evaluation including coagulation studies as well as a bleeding time may be a valuable diagnostic tool, which may suggest the need for more sophisticated bleeding evaluation.
• Toxicology screens may be indicated if the clinical situation suggests a possible ingestion as the cause of the findings on examination and evaluation.
• Serum tests for abdominal injury (eg, amylase levels, checking for blood in stool and urine) may also be indicated.
• Liver enzyme levels such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are used most often for liver injury.
• Amylase and lipase levels are used for pancreatic injury.
• Urine analysis for red cells may be helpful in evaluating for urinary tract injury.

Imaging Studies

• For children younger than 2 years suspected of having been abused physically, a skeletal survey is recommended to rule out skeletal injury, both new and old. The AAP guidelines define the components of a skeletal survey as anteroposterior (AP) views of humeri, forearms, hands, femurs, lower legs, feet, chest/ribs, pelvis; lateral view of the axial skeleton in infants; and AP and lateral views of the skull.
• Depending on history and physical examination, other diagnostic and imaging tests may be indicated including the following:
  • Radionuclide bone scanning, which assists in identifying new rib fractures and subtle long bone fractures not apparent on the skeletal survey
  • CT scanning of the head, which is indicated in any child suspected of inflicted head trauma in order to image the brain and assess for injury
  • CT scanning of the thorax and abdomen, which may be helpful to view the organs in the chest and abdomen if injury is suspected
  • MRI, which can be a valuable adjunct to the head CT scan because it can further define an injury and identify different ages of blood contained in an subdural hematoma

Treatment

Medical Care

Treatment for physical abuse is a complex endeavor involving an interdisciplinary team approach. The nature of the injury determines the form of medical therapy, and the details of the caregiving environment determine the psychosocial supports needed to keep the child safe.

• For medical issues, skeletal fractures of the long bones may require casting, and orthopedics should be consulted for assistance with diagnosis and management.
• If clinical consideration is being given to the possibility of osteogenesis imperfecta (OI), a genetics consultation may also be valuable.
• Burns vary in severity and treatments range from cleansing the area to skin grafting.
  • Plastic surgery should be consulted for assistance with management of more serious burns; transfer to a burn unit may be indicated.
  • See Initial Evaluation and Management of the Burn Patient for burn management.
• The most severely injured children, such as those with CNS injury, may require resuscitation and will need intensive care.
  • A multitude of specialists may need to be involved in order to correctly evaluate and treat these seriously ill children.
  • Whenever shaken baby syndrome is suspected, ophthalmology should be consulted for a formal evaluation, including examination of the eyes for retinal hemorrhages.
• Psychosocial management that requires a significant amount of coordination among various services providers, including the physician and other health care providers, complements the medical management. Child protective services (CPS) agency in each community is responsible for performing investigations of cases in which physical abuse is suspected and relies on the physician to provide the details of the medical evaluation. In addition, CPS assesses the caregivers' background, caregiving abilities and potential, environmental safety, risk for repeat abuse, and risk to other siblings. A variety of treatment options are available, ranging from periodic contact with the child and family to removal of the child from the home, either temporarily or permanently, with termination of parental rights. The CPS process for child maltreatment cases typically involves the following steps:
  • Intake - Screening of reports and acceptance of case
  • Initial risk assessment - Caregiver interviews, medical information gathering, home evaluation, and possibility of contact with law enforcement
  • Case planning - Determination of safety for the child with essentially 3 options: (1) the child goes home with the caregiver with or without services depending on the circumstances, (2) the child is removed from home and family with caregivers consent and offered services to assist them in working towards reunifying with the child, and (3) the child is removed from the home and family without caregiver's consent, involving court action and incorporation of legal steps and processes to determine the ultimate plan for the child.

Consultations

• Pediatric radiologist - If dating of bone injuries become central to the maltreatment investigation
• Orthopedics - For assistance with diagnosis and management in cases of skeletal fractures of the long bones
• Genetics - For detailed workup for OI and the characterization of the collagen disorder
• Plastic surgery - For assistance with management of serious burns
• Ophthalmology - Whenever abusive head trauma (AHT)/shaken baby syndrome (SBS) is suspected, for a formal evaluation including examination of the eyes for retinal hemorrhages
• Child psychiatrist, behavioral-developmental pediatrician, or psychiatric social worker to assess the mental health needs of child and family as well as coordinate overall psychosocial treatment plan

Follow-up

Patient Education

• For excellent patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education articles Child Abuse and Bruises.

Miscellaneous

Medicolegal Pitfalls

• Physicians are mandated to report suspicions of physical abuse to the proper governmental authorities in all 50 states. Some states may require notification of law enforcement officials; other states may require notification of both law enforcement and child protective services (CPS). Notification requirements applicable to the physician's practice setting are found in each state's laws.
  • Suspicion of abuse typically is defined as when information before the physician would lead a competent professional to conclude that physical abuse is likely to have occurred. It should be noted that the physician participates in the evaluation of abuse but does not have the responsibility to prove that it has occurred or to determine the identity of the abuser. The law enforcement and court system have these responsibilities.
  • Once the report is made, usually in the form of a call to the state or county hotline followed by some form of written documentation, the state laws outline a time line for the subsequent evaluation.
  • CPS will screen the information, conduct an investigation, and provide supportive services for the child and family.
  • Law enforcement may become involved, depending on the locality and the circumstances of the case.
  • Under state statute, the physician making the report in good faith is able to claim immunity from criminal and civil liability should an angry caregiver file a lawsuit against the physician for making the report, even if, ultimately, it is determined that no maltreatment has occurred.
  • Additionally, the physician who fails to make a report of suspected abuse may be held liable for failing to report the case under the state's statutes.
• The physician's documentation is vital to the investigation of physical abuse. This documentation should offer a time-sequenced record of the information surrounding the case and should contain specific information, including when physical abuse became known.
• Because these cases have tremendous legal implications for the child and caregivers, it is important to create a clear, accurate medical record, which preserves the medical details of the case. Reliance on memory several years after the physician has evaluated a case will not serve the interests of the child and caregivers; whereas a well-documented medical record will serve these interests. The medical record may be admitted as evidence in any subsequent court actions involving the case and will be invaluable to the physician if called to testify in any court proceedings. Documentation should include the following:
  • Statements made by the child and caregivers on presentation for care
  • Details of the child's medical history and interview
  • Caregiver(s) interview(s)
  • Physical examination findings
  • Laboratory/diagnostic imaging studies results
  • Medical conclusions drawn from the collective information
• Marx offers general documentation guidelines regarding the medical record related to statements made to the health care provider as follows:
  • Name of person making statement and his relationship to the child
  • Date and time that statement was made
  • Any questions, statements, or actions by the health care provider occurring before or possibly prompting the statement
  • Where possible, exact words of the statement using quotation marks to identify
  • Demeanor of the person making the statement
  • Others present when statement was made
  • Name and other identifying information of the person recording the information into the medical record
• With regard to the child and caregiver interviews, documentation needs to reflect details surrounding the injury, including what was happening before the injury, the circumstances of the injury, and what happened after the injury. The physical examination and laboratory/diagnostic imaging workup should be documented as clearly as possible, complete with drawings and photographs of the injury. Specifically regarding photographs, the following advice is offered:
  • Clearly include the child's name and medical record number in the photo.
  • Include a centimeter ruler and color balance chart.
  • If possible, rephotograph the injuries during the healing process to show the progression/resolution of the injury.
  • Avoid instant film in favor of 35 mm film to achieve better quality photos.
  • Supplement photos with drawings in the chart because photos may fail to develop properly or may be lost during months to years of storage.
• At the conclusion of the medical evaluation, it is important that the physician sifts through all the information known at that time and develops an impression and a set of treatment plans. Understand that additional information may be uncovered in later phases of the investigation; conclusions drawn should not overstate the certainty of what was known at that point in time.
  • The physician should summarize the clinical information from the history and interviews, physical examination, and laboratory and diagnostic studies, state whether the injury evaluated is consistent with the explanation provided or if it is inconsistent, and state why. Statements such as "no evidence of abuse" do not recognize that the investigation may uncover additional information that may contradict this statement.
  • Additionally, statements reflecting personal opinions about the child and caregivers are not appropriate for the medical record, because they may be misinterpreted easily.
• In cases of physical abuse, the child and/or physician may be asked to testify in court. A physician may be called to testify in a child maltreatment case in the following 2 capacities:
  • The lay (fact) witness is asked to recount personal knowledge regarding the maltreatment events; usually, this entails describing what the findings were when the child presented for care and evaluation. The physician serving as a lay witness typically is asked to explain what they put in the child's medical record and how conclusions were drawn at the time of the medical evaluation.
  • In contrast, the expert witness is asked to provide the court with technical, clinical, and scientific information. The expert witness may offer opinions about certain medical facts in the case and does not need to have evaluated the child in question. An attorney in the case qualifies an expert witness by demonstrating to the judge that the physician has advanced knowledge in the form of training and experience. The expert can offer opinions but is not permitted to say whether the child is telling the truth; that is the role of the court.
• Child testimony in court proceedings is an area of special concern because the court represents a formal adult setting that handles often contentious adult arguments. The AAP has issued a policy statement regarding children in court and specifically addresses the unique stress that the courtroom may cause for children called to testify in court proceedings regarding their own maltreatment.
  • Appearing in court creates anxiety, and no agreement exists about whether it is positive or negative for the child to face their alleged abuser in such a setting.
  • Children may testify in court if they can relay and receive information accurately, know the difference between telling the truth and a lie, and understand the need to tell the truth in court.
  • If the child is asked to testify, the pediatrician needs to be aware of the high levels of anxiety that inevitably will arise and assist the child and family in anticipating and planning around this effect.
• Finally, one of the best ways to serve a child's best interests in legal proceedings is for physicians to carefully and accurately document in the medical record. A well-constructed chart containing all pertinent information has the greatest chance of speaking for the child's interests. Therefore, meticulous documentation is essential for child maltreatment cases.

Multimedia

Media file 1: Handprint on face. Image courtesy of Lawrence R. Ricci, MD.

Media file 2: Handprint on leg. Image courtesy of Lawrence R. Ricci, MD.

Media file 3: Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.

Media file 4: Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.

Media file 5: Bruises inflicted with switch. Image courtesy of Lawrence R. Ricci, MD.

Media file 6: Switch - Object used in Media files 4-5. Image courtesy of Lawrence R. Ricci, MD.

Media file 7: Bruises inflicted with wooden spoon. Image courtesy of Lawrence R. Ricci, MD.

Media file 8: Bruises inflicted with belt. Image courtesy of Lawrence R. Ricci, MD.

Media file 9: Buckle fracture distal femur shaft. Image courtesy of Lawrence R. Ricci, MD.

Media file 10: Duodenal hematoma. Image courtesy of Lawrence R. Ricci, MD.

Media file 11: Burn from car seat. Image courtesy of Lawrence R. Ricci, MD.

Media file 12: Car seat. Image courtesy of Lawrence R. Ricci, MD.

Media file 13: Model for Media file 14. Image courtesy of Lawrence R. Ricci, MD.

Media file 14: Femoral neck fracture from being yanked from previous crib. Image courtesy of Lawrence R. Ricci, MD.

Media file 15: Inflicted pinch mark shaft. Image courtesy of Lawrence R. Ricci, MD.

Media file 16: Burn from being held down on hot cement. Image courtesy of Lawrence R. Ricci, MD.

Media file 17: Old and new radius fracture. Image courtesy of Lawrence R. Ricci, MD.

Media file 18: Child with slap mark. Image courtesy of Lawrence R. Ricci, MD.

Media file 19: Same child as in Media file 18, with old radius and ulna fracture. Image courtesy of Lawrence R. Ricci, MD.

Media file 20: Same child as in Images 18-19, with multiple rib fractures. Image courtesy of Lawrence R. Ricci, MD.

Media file 21: Sunburn. Image courtesy of Lawrence R. Ricci, MD.

Media file 22: Burn inflicted with lighter. Image courtesy of Lawrence R. Ricci, MD.

Media file 23: Acute subdural with shift. Image courtesy of Lawrence R. Ricci, MD.

Media file 24: Fingernail scratch in same child with subdural shown in Media file 23. Image courtesy of Lawrence R. Ricci, MD.

Media file 25: Ecological model for understanding violence.

Media file 26: Overlap of child maltreatment and domestic violence.

Media file 27: US child maltreatment trends.

Media file 28: Adverse child experiences pyramid.

Media file 29: National Pediatric Trauma Group registry findings.

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Keywords

physical abuse, child maltreatment, child abuse, victimization, physical maltreatment, intentional injury, nonaccidental injury, inflicted injury, fracture, burn, bruise, subdural hematoma, SDH, abusive head trauma, AHT, shaken baby syndrome, SBS, shaking-impact syndrome, maltreatment, domestic violence, corporal punishment, fractures, whiplash syndrome, smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, ischemic heart disease, cancer, stroke, chronic bronchitis, emphysema, diabetes, hepatitis, skeletal fractures

Contributor Information and Disclosures

Author

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Coauthor(s)

Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC, Associate Professor of Nursing, Department of Acute and Continuing Care, University of Texas Health Sciences Center Houston School of Nursing
Eileen R Giardino, PhD, RN, MSN, FNP-BC, ANP-BC is a member of the following medical societies: American Academy of Nurse Practitioners, American College Health Association, American Nurses Association, American Professional Society on the Abuse of Children, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

The authors gratefully acknowledge the assistance of Dr. Lawrence R. Ricci in providing photographs to illustrate the various injuries that may be seen when evaluating children for suspected physical abuse. Despite being a busy clinician, educator and academic leader, Dr. Ricci made time to select cases for this article from his large archive. 

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