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Physical Abuse
Key Concepts
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The ultimate determination of whether abuse has occurred can take days or weeks. Emergency clinicians should focus on recognizing possible abuse, treating medical injuries, and establishing a safe disposition for the child.
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Completely undress infants and preverbal children for the physical examination; pay particular attention to the skin, ears, mouth and oral cavity, scalp, fontanel, and genitalia.
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Consider abuse routinely for sentinel injuries in young children without an independently witnessed traumatic mechanism. Sentinel injuries include the following: bruising in children younger than 6 months old; bruising on the torso, ears, neck, jaw, cheek, or eyelid; oral injuries; patterned cutaneous injuries; subdural hematoma; long-bone fractures in infants; intra-abdominal injuries; and rib fractures.
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Consider abuse for children when family violence (child abuse, intimate partner violence, elder abuse, or animal abuse) is recognized in the child’s home.
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The goal of diagnostic testing is to identify additional clinically or forensically significant injuries or medical entities that may present similarly to abuse.
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Use objective, nonaccusatory, matter-of-fact statements to communicate concern for abuse.
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Emergency clinicians in the United States, Canada, and many other countries are legally mandated to report reasonable concerns for abuse to public child protective services (CPS) agencies.
Foundations
Child physical abuse is a leading cause of death and disability for young children. In the United States (US), more than 120,000 children are victims of physical abuse leading to more than 550 preventable deaths each year. This means that large pediatric centers will see several cases of physical abuse each month, while smaller, general emergency departments (EDs) may go several months without a single case. Physical abuse is also commonly missed—approximately 30% of abusive head trauma and 20% of abusive fractures are missed on initial presentation. Physical abuse is especially difficult to identify, because it predominantly affects preverbal children, particularly those younger than 6 months old. , Caregivers frequently omit or obscure the true history, and key portions of the physical examination (e.g., neurologic and musculoskeletal examinations) are limited. Early recognition of abuse therefore often depends on identifying subtle, minor, or self-limited injuries. With these challenges, current practices are highly variable, and children are frequently returned to abusive environments. ,
Overcoming these challenges is essential for abused children and their families. Because violence is a disease that affects entire households, recognition of abuse is important not only for the children themselves, but also for their siblings, parents, elders, and even pets. For abuse survivors and those who share a violent household, the long-term health effects of toxic stress are severe, diverse, and widespread.
Role of the Emergency Clinician
It is rarely possible and almost never necessary to definitively diagnose abuse in the ED. Care of abused children involves the cooperation of medical, social, and law-enforcement agencies over weeks and months. Emergency clinicians are responsible for raising the initial concern for abuse and working with other professionals (e.g., general and child abuse pediatricians, CPS) to stratify risk, ensure safety, and arrange for ongoing care.
Most injuries in childhood are not the result of abuse, and unusual events may produce unusual or unusually severe injuries. Inevitably, some children who are evaluated for abuse will ultimately be determined to have an innocent explanation for their injuries. To facilitate the evaluation and preserve the doctor-patient relationship, emergency clinicians should use nonaccusatory statements to explain the need for testing ( Box 172.1 ). A routine, standardized approach to testing and reporting can improve abuse recognition and decrease racial and social disparities.
BOX 172.1
Communication Strategies
When Interviewing a Child About Abuse
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Open-ended, non-leading questions: “Tell me more about that.”, “How did your body feel?”, “Then what happened?”
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“What happens at your house when kids (or pets) get in trouble?”
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Frequently explain and ask permission: “I am going to ask you some questions about your health to make sure I provide the safest treatment. Is that ok? I’m going to examine your body to make sure you are healthy. Is that ok?”
To Introduce the Genital Examination for Young Children
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“I’m also going to examine your whole body to make sure that you are healthy. I’m going to look at your nose, your ears, your belly-button, and even under your undies.”
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“This examination is ok because I’m a doctor, because your mother is here, and because your mother says it’s ok.”
After the Examination
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“Your body looks completely healthy and normal. This does not make me doubt what you told me. It does mean that no one, not your spouse, your friends, or even a doctor like me will know what happened by looking at you.” Or, “Your body has some signs of injury, but these will heal very quickly, and in a few days, you will be completely back to normal. No one, not even…”
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“Despite what many people believe, doctors usually can’t tell whether someone has had sex by looking at their body. In fact, in one study of teens that were pregnant, almost 90% had completely normal examinations.”
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“In my opinion, someone stops being a virgin when they choose to have sex.”
Nonaccusatory Statements of Abuse Concern
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“The injuries we’ve identified are more than we would expect from the event you’ve described.”
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“Whenever we see injuries like this, we test for other injuries and medical conditions to be sure we’re not missing something that could affect your child’s health.”
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“I want to make sure that your child is safe/that no one is hurting your child.”
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“Have you ever been concerned that someone might have been rough with or might have injured your child?”
Clinical Features
The clinical features of physical abuse are listed in Box 172.2 .
BOX 172.2
Red Flags for Physical Abuse
Psychosocial Factors (Nonspecific, Do Not Use to Exclude Abuse)
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Unrelated caregiver (especially boyfriend) or new caregiver relationship
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Family violence
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Mental health disorders
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Substance use disorders
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Describing the child negatively
Historical Factors
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Significant injuries with no or minor trauma
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Significant inconsistencies in history
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Unexplained delay in seeking care
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Significant injury attributed to pets or young children
Physical Examination Factors
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Bruising, frenulum or conjunctival injury in children <6 months old, or who are not “cruising”
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Bruising on the torso, ear, neck, angle of the jaw, cheek, or eyelid
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Patterned bruising or burns
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Immersion or cigarette burns
Social and Demographic Risk Factors
Understanding psychosocial and demographic risks is most important for primary prevention efforts. , Despite increased data, these factors are relatively insensitive and nonspecific and should not be used to confirm or exclude abuse. Serious physical abuse has been reported in every socioeconomic setting, and even in households with several risk factors, the vast majority of caregivers do not physically abuse their children. Nevertheless, poor or African American families remain disproportionately likely to be evaluated and reported for abuse, while abuse is more likely to be missed in White or affluent families.
Physical abuse is more likely to occur with male caregivers, especially with new caregiving arrangements, or when the caregiver is an unrelated boyfriend. Prior involvement with CPS, intimate partner violence, substance use, mental illness, poverty, and criminal history have been associated with increased risk for abuse, as has the use of negative descriptors of children.
History
Abuse is challenging to recognize when a child presents with nonspecific symptoms and without a recognized traumatic injury. Fractures, abdominal injuries, and mild brain injuries can have a smoldering course of mild symptoms, such as irritability, vomiting, or decreased appetite or activity. , In these cases, identifying abuse is difficult and usually involves prolonged symptoms, additional clues on physical examination, known social risk factors, or prior concern for abuse. The Pittsburgh Infant Brain Injury Score (PIBIS) can be used in these cases to determine the need for neuroimaging ( Table 172.1 ).
TABLE 172.1
The Pittsburgh Infant Brain Injury Score (PIBIS)
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| Who present with |
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| Total points: 5; neuroimaging is recommended for children with scores of 2 or more. | |
Although still nonspecific, certain complaints should prompt consideration of abuse. A small percentage of children presenting with a brief, resolved, unexplained event (BRUE; formerly known as apparent life-threatening event (ALTE)) will have retinal hemorrhages or other abusive injuries. Occult fracture should be considered in young or preverbal children who present with decreased use of an extremity, fussiness, and localized tenderness or refusal to bear weight.
Regardless of the injury, unreasonable delay in seeking care should prompt concern for abuse. No precise time period defines an “unreasonable” delay, and physicians should consider the child’s symptoms and progression of disease. A delay of several hours is not uncommon for children with nonabusive fractures or abdominal injury. Conversely, even a brief delay can be concerning in children with obvious signs and symptoms such as seizures, coma, or substantial burns.
Serious injury without a history of trauma, or with a history of only mild trauma (e.g., caused by the child themselves, a young sibling, or a pet) should raise a high level of concern for abuse. Nontrivial intracranial hemorrhage is extremely uncommon from short falls (e.g., from a bed or a couch) and does not result from choking on formula or saliva. Abdominal and thoracic injuries rarely result from household falls, even with increased height or falls down stairs.
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