Skin Signs of Abuse

Introduction

Child abuse encompasses the broad spectrum of non-accidental maltreatment of children, including physical, emotional, and sexual abuse as well as neglect. Physical abuse is defined as non-accidental injury of a child; the injury may be the result of a single abusive episode or occur over a longer period of time. Two in 100 infants <1 year of age and one in 100 children 1–5 years of age are victims of abuse or neglect . In 2015, 8% of childhood injuries reported to the National Trauma Data Bank were due to intentional assault, and 6% of assault-related injuries resulted in the child's death . Abused children are generally younger and more likely to sustain serious intracranial, thoracic, and abdominal injuries than children who are injured accidentally . Infants and younger children are at greater risk because they are demanding, less verbal, and defenseless.

Parents may describe abused children as “difficult”, which in fact may be true; however, the parents' attempts to intervene in an excessive and inappropriate manner constitute abuse. Premature infants, disabled children, and children with behavioral problems are at increased risk of abuse. Parents who abuse their children were often themselves abused as children. They are frequently immature, dependent, socially isolated individuals. Often, they do not handle stress well, and a personal or family crisis may trigger an abusive episode. It is important that all physicians recognize signs of physical abuse in children, as it tends to be repeated, and an intentionally injured child is at high risk for severe physical injury in the future.

Physical neglect is a failure to provide the necessities of life for a child, including nutrition, clothing, housing, medical care, and a safe, supervised environment. Emotional abuse or neglect results when parents fail to provide a nurturing environment that permits the child to grow and reach his or her full potential.

Sexual abuse can be defined as engaging a child in a sexual activity that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and/or that violates the social and legal taboos of society . The child's involvement may be coerced with physical threats, rewarded through bribes, or induced via misrepresentation of moral values. Sexual abuse can be assaultive or non-assaultive. Non-assaultive sexual abuse often goes unreported since there is usually little or no physical injury to the child. In contrast, assaultive sexual abuse is characterized by physical injury and violence. Both types of sexual abuse may result in severe emotional trauma to the child.

History

Maltreatment of children has always existed, but in 1946, Dr John Caffey, a pediatric radiologist, initiated medical concern about child abuse by reporting six children who presented with skeletal fractures and subdural hematomas that were clearly related to trauma . The immense importance of this problem was not generally recognized until 1962, when Kempe et al. coined the term battered child syndrome , the findings of which include inadequately explained signs of trauma, multiple fractures at different stages of healing, and/or failure to thrive that responds to nutritional therapy or placing the child in an emotionally supportive environment.

Epidemiology

Child abuse is a worldwide problem that occurs among all ethnic and racial groups and in families of all socioeconomic and educational levels. In the US, single-parent families with incomes below 200% of the poverty threshold have much higher probabilities of violence . Child abuse occurs more frequently when other problems such as unemployment, substance abuse, unplanned pregnancies, or discord between parents increase the stress on individuals within the family. Boys are at greater risk for serious injury than are girls, and infant boys have the highest fatality rate .

The perpetrator of sexual abuse is often a person well known to the child, most often the natural father, followed in frequency by a step­father or another close relative. Although reports of abuse are about three times more likely in girls than in boys , sexual abuse in boys may be more likely to go undetected and/or unreported. The risk for sexual abuse rises during preadolescence and in family situations with a stepfather in the household, children living without one or both of their natural parents, and children whose mothers are disabled, ill, or extensively out of the home .

Clinical Features