EMERGENCY CASE CONFERENCE
Child Abuse Judith E. Tintinalli- editor Detroit, Michigan
Tintinalli JE: Child abuse, JACEP 7"110-113, March, 1978. child abuse; battered child.
INTRODUCTION
Judith E. T i n t i n a l l i , MD: The s t i m u l u s for this conference on child abuse was the case of a one-year-old child, brought to the Emergency D e p a r t m e n t of Children's Hospital of Michigan, and pronounced dead on arrival - - a victim of obvious child abuse. S. K. Grover, MD, staff emergency physician at Children's Hospital, is the guest speaker. S. K. Grover, MD: Child abuse has existed for centuries, occasionally with c u l t u r a l approval. Radbill, 1 in his detailed review, traces child abuse back five t h o u s a n d years. Children were killed by r i t u a l sacrifice to the gods in C h i n a and India. During the crusades, i n f a n t a b a n d o n m e n t was common, and d u r i n g the i n d u s t r i a l revolution, children were beaten and treated as slaves. Young boys and girls have been used for sexual purposes. The case of ~'Mary Ellen," a child who was beaten and starved by her adoptive parents in New York City in 1874, led to the founding of the Society for the P r e v e n t i o n of Cruelty to Children in the United States. At t h a t time, there were laws a g a i n s t the b e a t i n g and s t a r v i n g of a n i m a l s but there were none to protect children. The clinical recognition of child abuse began in 1946 when C affey 2 reported an association between subdural h e m a t o m a a n d fractures of the long bones i n infants. In 1953, Silverman 3 reported on the radiologic manifestations of clinically unrecognized skeletal t r a u m a in infants. In 1955, Wooley and E v a n s 4 described certain forms of skeletal t r a u m a in children that were a result of child abuse. Kempe et aP coined the term ~battered child syndrome" in 1961. The battered or abused child is defined by Kempe s as any child who receives nonaccidental injuries, or injuries as a result of acts of omissions, on the part of his parents or guardians. In my opinion, the term ~'battered child syndrome" is a f r i g h t e n i n g and emotional phrase, and I prefer the use of terms such as inflicted or nonaccidental injury (NAI). Physical neglect is the failure to provide the child's necessities of life, such as medical care, food, clothing, or parental supervision. Child abuse is one of the few crimes i n which the abuser and the victim will be united again as a m a t t e r of course. If children who have been physically abused or neglected are r e t u r n e d to their parents, w i t h o u t professional counseling, there is about a 50% chance t h a t abuse will be repeated, and a 10% chance of d e a t h 2 Half of established abuse cases show evidence of prior abuse. G Children who are the victims of child abuse may well encounter difficulties with the law as they grow up, and may become the child abusers of the next generation. In the U n i t e d States, the estimated incidence of child abuse varies from 60,000 to 500,000/year2, 7 At least 400 deaths per year are a result of child abuse. 6 At Children's Hospital of Michigan, d u r i n g the period 1964 to 1976, 1,619 cases were reported. From J a n u a r y to October 1977, 298 cases of child abuse and 260 cases of child neglect have been reported (Table). Although the true incidence of child From the Emergency Department, Detroit General Hospital, Section on Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan. Address for reprints: Judith E. Tintinalli, MD, Detroit General Hospital, 1326 St. Antoine, Detroit, Michigan 48226. 7:3 (Mar) 1978
JACEP
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"dirty little son of a bitch," m a y leave p e r m a n e n t emotional scars.
Table CHILD ABUSE AND NEGLECT
PROFILE OF ABUSE
Children's Hospital of Michigan, 1964-October 1977
1964 - 1
1971 - 128
1965 - 12
1972 - 134
1966 - 20
1973 - 233
1967 - 50
1974 - 238
1968 - 58
1975 - 274
1969 - 103 1970 - 109
1976 - 290 1977 - 298-Child 260-Child
The abusive p a t t e r n consists of three factors: the abusive p a r e n t or guardian; the abused child, and the t r i g g e r i n g event. G r e e n 6 h a s a d d e d a fourth factor, c u l t u r a l tolerance. The profile of the abusing p a r e n t consists of att r i b u t e s which have been acquired over a lifetime. The p a r e n t s of abused children m a y t h e m s e l v e s have been abused, neglected, or i n a p p r o p r i a t e l y m o t h e r e d d u r i n g childhood. The individual who h a s no realistic way of h a n d l i n g the problems of his or her children m a y fall into a p a t t e r n of child abuse. Often an abusive p a r e n t possesses low self esteem while at the same t i m e he or she d e m a n d s u n r e a l i s t i c a l l y h i g h performance of the child. The p a r e n t is u s u a l l y incapable of responding to the basic needs of the child, and, in fact, m a y desire support from the child, r a t h e r t h a n the reverse. Often, the p a r e n t d e m o n s t r a t e s gross inconsistencies in his or h e r r e l a t i o n s h i p w i t h the child. This inconsistency m a y v a r y from a lack of d e m o n s t r a t i v e n e s s to emotional over-involvement, and m a y range from l a x i t y to e x t r e m e physical p u n i s h m e n t , s The spouse m a y be unsupportive, or m a y p l a y a passive role by i g n o r i n g abusive behavior in his or h e r mate. The child a t risk for abuse or neglect is the child who is perceived as d e m a n d i n g or difficult to satisfy by the a b u s i n g parent, a l t h o u g h in fact he m a y be no different from other children. The p r e m a t u r e infant, the u n w a n t e d or i l l e g i t i m a t e child, the r e t a r d e d or h y p e r k i n e t i c child, is more likely to be abused. The colicky infant, who feeds poorly and cries often, can produce severe stress in a h i g h - r i s k parent. B a t t e r i n g is more likely when a child is sick. The t r i g g e r i n g crisis is a p r e c i p i t a t i n g event, e i t h e r major or minor, in t h e r i g h t setting. Occurrences such as a death, divorce, loss of a job, or even a b r o k e n television set, can be the t r i g g e r i n g event. A fourth factor, c u l t u r a l tolerance, ~ can be import a n t if the c o m m u n i t y accepts corporal p u n i s h m e n t as a l e g i t i m a t e form of discipline.
Abuse, Neglect
abuse will probably n e v e r be known, the reported figures are probably fairly reliable in centers with an active child abuse education program. In the U n i t e d States, about 10% of injuries seen in children under three y e a r s of age are nonaccidental. 6 About 30% of fractures in children under two are the r e s u l t of abuse. ~ It is e s t i m a t e d t h a t of t h e child victims of physical abuse, one t h i r d are u n d e r the age of 6 months; one t h i r d are between 6 months and 3 y e a r s of age, and one t h i r d a r e over 3 y e a r s of age. In m y experience, p r e m a t u r e infants and step-children a p p e a r to be at g r e a t e r risk for abuse. More m a l e s t h a n females are physically abused, although sexual abuse is more common in females. ~ A b u s i n g p a r e n t s come from all social s t r a t a . Women are more often involved in child abuse t h a n men, a l t h o u g h when fathers are unemployed and at home, t h e y a p p e a r to inflict child abuse to the same degree as the mothers. Men t e n d to inflict more serious injury. In m y experience, the m a j o r i t y of a b u s i n g parents are married, of average intelligence, and between 20 to 35 y e a r s of age. CATEGORIES OF ABUSE Child b a t t e r i n g m a y involve physical or s e x u a l abuse, n u t r i t i o n a l or m e d i c a l neglect, or e m o t i o n a l abuse. Physical abuse consists of the infliction of inj u r i e s such as bruises, fractures, and burns. Three special injuries t h a t should raise a strong suspicion of batt e r i n g are u n e x p l a i n e d fractures, s u b d u r a l h e m a t o m a s , and r u p t u r e d a b d o m i n a l viscera. The real incidence of sexual abuse in c h i l d r e n is unknown, since most children will conceal such incidents, f e a r i n g social rejection or further abuse. G e n i t a l or p e r i n e a l injuries m a y be a result of sexual abuse. This a r e a deserves s e p a r a t e discussion, a n d will not be covered in today's talk. N u t r i t i o n a l d e p r i v a t i o n m a y be the cause of failure to thrive in a small n u m b e r of children. Neglect of medical care is a subtle form of abuse. E x a m p l e s of this include an a s t h m a t i c child who is not given his bronchodilators, or a diabetic not given his insulin. Court orders to hospitalize and t r e a t children are occasionally needed in s i t u a t i o n s which the p a r e n t s do not acknowledge or recognize as l i f e - t h r e a t e n i n g emergencies, such as the need for blood transfusions, or the necessity to hospitalize a child w i t h meningitis. E m o t i o n a l abuse is e x t r e m e l y difficult to diagnose and treat. While the pain of p h y s i c a l abuse m a y fade away, the d a m a g e done to a child's psyche from h a v i n g been locked in a closet, chained to a bed, or being called a s4/111
DIAGNOSIS OF CHILD ABUSE The physician's role in child abuse consists of the recognition a n d t r e a t m e n t of the abused child, and the r e p o r t i n g of suspected abuse or neglect to the appropriate agencies. One m u s t t h i n k of the possibility of abuse in order to recognize it. A h i g h index of suspicion, coupled with an organized clinical approach, is necess a r y for the detection of inflicted injuries. The emergency p h y s i c i a n plays a major role in the recognition, t r e a t m e n t , and even the p r e v e n t i o n of child abuse, since most often the child is t a k e n to a n emergency departm e n t for t r e a t m e n t . A p h y s i c i a n m a y have only one chance at the diagnosis, since frequently the abused child is t a k e n to a different hospital for each episode. The abused child m a y exhibit a characteristic vac a n t or unresponsive facies d u r i n g the e x a m i n a t i o n . In particular, children of 3 to 5 y e a r s of age m a y be abnorm a l l y well-behaved - - they'd b e t t e r be, for t h e i r lives m a y depend on it. Other c h a r a c t e r i s t i c s of the abused child include a wariness of physical contact w i t h adults. The child m a y not look to the p a r e n t for reassurance, or m a y cry helplessly d u r i n g the e x a m i n a t i o n 2 The p a r e n t ' s b e h a v i o r m a y be e q u a l l y inappro-
JACEP
7:3 (Mar) 1978
d u n k i n g type injury of the buttocks is suggested by the absence of b u r n s on the back and posterior thighs. B l u n t t r a u m a to the nose may result in the "pugilistic puss" - - broadening of the nose, with deviation of the nasal septum due to cartilaginous injury or h e m a t o m a formation. Along with n a s a l t r a u m a , there m a y be associated injuries each as bruised or lacerated lips, broken teeth, a n d periorbital, facial, or ear hematomas. Forced feeding is another form of abuse, and can result in b r u i s i n g or laceration of the lips or tongue. A blow to the ear m a y r u p t u r e the t y m p a n i c membrane. Multiple skeletal injuries, w h e t h e r old or new, suggest inflicted injury. A spiral fracture of a long bone may be produced by forceful twisting of the extremity. Children who cannot walk are u n l i k e l y to incur such an injury accidentally. Metaphyseal fraying can be produced by twisting t r a u m a . The firm periosteal attachm e n t at the metaphysis is broken offas a chip fracture. 9 B l u n t s k e l e t a l t r a u m a can produce s u b p e r i o s t e a l hemorrhage, which leads to periosteal elevation and e v e n t u a l subperiosteal calcification. 5 Cupping at the ends of long bones, especially the femur, is suggestive of nonaccidental injury. 12 Violent shaking can produce a subdural h e m a t o m a if i n t r a c r a n i a l bridging veins are lacerated or torn, and funduscopic e x a m i n a t i o n may demonstrate r e t i n a l hemorrhages. 11 Rib fractures, u s u a l l y m u l t i p l e a n d i n various stages of healing, may result from b l u n t injury to the chest. Abdominal injury is a common cause of death in battered children. Blows to the abdomen can cause contusion or r u p t u r e of the viscera, especially the liver, or can result in a pancreatic pseudocyst. In the child with suspected abuse, a skeletal survey should always be performed. If there are m u l t i p l e bruises, or a history of easy bruising, a coagulation survey should be obtained. Color photographs should be t a k e n to document any physical findings.
priate. He or she may display little or no response to the crying child, and may seldom touch or look at him. A suspicion of abuse should arise if the p a r e n t cannot explain the history of the accident satisfactorily. In one child I treated, a skull fracture in a two-month-old inrant was explained by the i n f a n t rolling off the couch onto a carpeted floor. The p a r e n t may present contradictory histories on separate occasions, or may be reluctant to provide information regarding the injury. He or she may display anger at being questioned, may be angry with the child for being hurt, may exhibit little concern about the injury, or may show overconcern. There may be a prolonged interval between the occurrence of injury and the visit for t r e a t m e n t . Occasionally, a n abusive p a r e n t may fail to visit the child d u r i n g hospitalization, or may disappear immediately after the child's admission. The presence of multiple injuries involving various body surfaces, often in various stages of healing, should arouse the suspicion of abuse. In one series of autopsies performed on battered children, 50% of the deaths were due to a subdural hematoma, and 25% were due to a ruptured viscus. 7 About 10% of b u r n s in children are secondary to abuse. 9 Clinical findings suggestive of abuse are failure to thrive, perioral injuries, fractures in a child u n d e r age 3, frequent injuries, old healed fractures on x-ray films bizarre injuries, advanced u n t r e a t e d disease, genital or perianal t r a u m a , clearly demarcated burns, subdural hematomas, skull fractures, or ruptured viscus. ~ U n c o m m o n manifestations of nonaccidental injury include isolated r e t i n a l hemorrhages, s u b g a l e a l hematomas due to h a i r pulling, h a n d p r i n t bruises, h u m a n bites, i n t r a m u r a l h e m a t o m a s of the bowel, pancreatic pseudocysts, h y p e r n a t r e m i c dehydration in a n older child, or repeated overdose with tranquilizers2 ° On physical examination, the presence of certain types of injuries should raise a suspicion of inflicted injury. Bruises on a n i n f a n t who is totally dependent on others for care m e a n s inflicted injury, whereas this is not necessarily true of b r u i s i n g in a n older child. If the child is struck or beaten with a hard object, such as a belt buckle, or hand, the i m p r i n t of the object is generally left on the skin. Flexible objects such as belts, whips, or cords generally leave a sharp line of demarcation between injured and n o n i n j u r e d skin. Restraints applied to the ankles or wrists leave circumferential bruises or abrasions. Bruises at the corners of the m o u t h may be due to gags. H u m a n bite m a r k s are characterized by a distinctive crescent shape. The bite made by a child will have a narrow arch, while a n adult impression will be left by molar teeth. Dogs and other carnivores generally tear the flesh, whereas h u m a n bites compress the flesh resulting in contusion. Burns, w h e t h e r accidental or inflicted, are common childhoo~'injuries. Most accidental b u r n s occur d u r i n g the ages of 18 months to 5 years. The physician m u s t consider the age of the child and the location and severity of the b u r n in relation to the history, in order to establish the etiology. Cigarette or lighter b u r n s on the palms, soles, or buttocks, are common inflicted injuries. A fresh b u r n should be differentiated from bullous impetigo. One child I saw had wrist b u r n s produced by his mother, as a p u n i s h m e n t for repeatedly t u r n i n g on the gas jets of the stove. Inflicted scalding burns, often produced by i m m e r s i n g the child's buttocks, hands, or feet in hot water, are suggested by distinct b u r n margins. A
7:3 (Mar) 1978
LEGAL OBLIGATIONS Since 1963, the laws of every state mandate the reporting of child abuse. Laws vary from state to state, often with little uniformity regarding the i n d i v i d u a l s responsible for reporting and the ultimate responsibility for investigation and m a n a g e m e n t . Q u e s t i o n : Who can report child abuse, and is it a legal obligation? Dr. ( ] r o v e r : In Michigan, child abuse and neglect m u s t be reported by any professional involved with the child, such as the physician, coroner, school nurse or counselor, or law enforcement officer. In addition, any individual, including a n o t h e r child, can report suspected abuse or neglect. Most cases of abuse or neglect are filed by hospital personnel. If it is reported from outside the hospital, the child is generally brought to the hospital for court evaluation. In Michigan, a person required to report a n episode who fails to do so is civilly liable for any damages resulting from the failure to report the incident. The physician must notify the parents t h a t the incident will be reported, and t h a t they will be contacfed by the local child welfare agency. He can state t h a t this is being done out of concern for the child. If the physician has difficulty facing the family, he can also state that he is obligated to follow his course of action under the law. It is best to be honest and straightforward with the parents. The physician should m a i n t a i n a concerned, n o n j u d g m e n t a l , n o n a c c u s a t o r y a t t i t u d e toward the family. If he is u n s u r e of the diagnosis, consultation
JACEP
112/55
an effective force in stirring the c o m m u n i t y and its agencies to give these children a n d their families the care they need.
should be sought. In general, the child should be hospitalized unless t h e physician has strong feelings t h a t the child can be safely treated and evaluated in the home. Q u e s t i o n : Why are physicians r e l u c t a n t to report child abuse? Dr. G r o v e r : There are m a n y reasons. The physician may not comprehend that the injury is the result of abuse. He may s h u n personal involvement, he may fear t h a t medical confidentiality will be broken, or he may fear a negative economic effect on his practice. He may even agree with the philosophy of physical punishment. s In 1972, a California court 7 awarded $600,000 to a battered child because the physician and hospital failed to report a n incident of abuse, and the child e v e n t u a l l y suffered serious injury. If anything, this type of legal and financial persuasion should encourage physicians to comply with the law. Q u e s t i o n : W h a t do you do if the family refuses to have photographs t a k e n of the child, or if they refuse hospitalization? Dr. G r o v e r : In t h a t case, our hospital may keep the child in protective custody, and a court order is obtained, usually w i t h i n several hours, to allow the professionals to proceed in the interests of the child. In large as well as small communities, the resources for the counselling of abused children and their families are generally sorely lacking. There are no simple remedies to this multifaceted problem. The b e g i n n i n g of the solution often lies with the phyaician. The recognition and appropriate medical m a n a g e m e n t of inflicted injury, and the reporting of such incidents to the appropriate agency, are the i n i t i a l steps. Court appearances will most often be necessary a n d the child's lawyer will need the full cooperation of the physician because the evidence of abuse is almost always circumstantial. In addition, the physician may find t h a t he himself can be
56/113
REFERENCES 1. Radbill S: A history of child abuse and infanticide, i~ Helfer RE and Kempe CH. (eds): The Batterec7 Child. Chicago, University of Chicago Press, 1968. 2. Caffey J: Multiple fractures in long bones of infants suffering from chronic subdural hematoma. A m J Roentgenol R a d i u m Ther Nucl Med 56:163, 1946. 3. Silverman FN: Roentgen manifestations of unrecognized skeletal trauma in infants. A m J Roentgenol R a d i u m Ther Nucl Med 69-'413, 1953. 4. Wooley PV, Evans WA Jr: Significance of skeletal lesions in infants resembling those of traumatic origin. J A M A 158:539, 1955. 5. Kempe CH, Silverman FN, Steele BF, et al: The battered child syndrome. J A M A 181"17, 1962. 6. Green FC: Child abuse and neglect. Pediatr Clin North A m 22:329-339, 1975.
7. Brown RH: The battered child syndrome. J Forensic Sci 21:65-70, June 1976. 8. Smith SM, Hanson R: Interpersonal relationships and child-rearing practices in 214 parents of battered children. B r J Psychol 127:513-25, 1975. 9. Starbuck GW: The recognition and early management of child abuse. Pediatr A n n 5:146-154, 1976. 10. Kempe CH: Uncommon manifestations of the battered child syndrome. A m J Dis Child 129:12~5-126% November 1975. 11. Caffey J: Whiplash shaken infant syndrome. Pediatrics 54:396-403, 1974. 12. Caffey J: The parent-infant traumatic stress syndrome. A m J Roentgenol R a d i u m Ther N u c l Med 114:218-229, 1972.
JACEP
7:3 (Mar) 1978
Child Abuse Judith E. Tintinalli- editor Detroit, Michigan
Tintinalli JE: Child abuse, JACEP 7"110-113, March, 1978. child abuse; battered child.
INTRODUCTION
Judith E. T i n t i n a l l i , MD: The s t i m u l u s for this conference on child abuse was the case of a one-year-old child, brought to the Emergency D e p a r t m e n t of Children's Hospital of Michigan, and pronounced dead on arrival - - a victim of obvious child abuse. S. K. Grover, MD, staff emergency physician at Children's Hospital, is the guest speaker. S. K. Grover, MD: Child abuse has existed for centuries, occasionally with c u l t u r a l approval. Radbill, 1 in his detailed review, traces child abuse back five t h o u s a n d years. Children were killed by r i t u a l sacrifice to the gods in C h i n a and India. During the crusades, i n f a n t a b a n d o n m e n t was common, and d u r i n g the i n d u s t r i a l revolution, children were beaten and treated as slaves. Young boys and girls have been used for sexual purposes. The case of ~'Mary Ellen," a child who was beaten and starved by her adoptive parents in New York City in 1874, led to the founding of the Society for the P r e v e n t i o n of Cruelty to Children in the United States. At t h a t time, there were laws a g a i n s t the b e a t i n g and s t a r v i n g of a n i m a l s but there were none to protect children. The clinical recognition of child abuse began in 1946 when C affey 2 reported an association between subdural h e m a t o m a a n d fractures of the long bones i n infants. In 1953, Silverman 3 reported on the radiologic manifestations of clinically unrecognized skeletal t r a u m a in infants. In 1955, Wooley and E v a n s 4 described certain forms of skeletal t r a u m a in children that were a result of child abuse. Kempe et aP coined the term ~battered child syndrome" in 1961. The battered or abused child is defined by Kempe s as any child who receives nonaccidental injuries, or injuries as a result of acts of omissions, on the part of his parents or guardians. In my opinion, the term ~'battered child syndrome" is a f r i g h t e n i n g and emotional phrase, and I prefer the use of terms such as inflicted or nonaccidental injury (NAI). Physical neglect is the failure to provide the child's necessities of life, such as medical care, food, clothing, or parental supervision. Child abuse is one of the few crimes i n which the abuser and the victim will be united again as a m a t t e r of course. If children who have been physically abused or neglected are r e t u r n e d to their parents, w i t h o u t professional counseling, there is about a 50% chance t h a t abuse will be repeated, and a 10% chance of d e a t h 2 Half of established abuse cases show evidence of prior abuse. G Children who are the victims of child abuse may well encounter difficulties with the law as they grow up, and may become the child abusers of the next generation. In the U n i t e d States, the estimated incidence of child abuse varies from 60,000 to 500,000/year2, 7 At least 400 deaths per year are a result of child abuse. 6 At Children's Hospital of Michigan, d u r i n g the period 1964 to 1976, 1,619 cases were reported. From J a n u a r y to October 1977, 298 cases of child abuse and 260 cases of child neglect have been reported (Table). Although the true incidence of child From the Emergency Department, Detroit General Hospital, Section on Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan. Address for reprints: Judith E. Tintinalli, MD, Detroit General Hospital, 1326 St. Antoine, Detroit, Michigan 48226. 7:3 (Mar) 1978
JACEP
110/53
"dirty little son of a bitch," m a y leave p e r m a n e n t emotional scars.
Table CHILD ABUSE AND NEGLECT
PROFILE OF ABUSE
Children's Hospital of Michigan, 1964-October 1977
1964 - 1
1971 - 128
1965 - 12
1972 - 134
1966 - 20
1973 - 233
1967 - 50
1974 - 238
1968 - 58
1975 - 274
1969 - 103 1970 - 109
1976 - 290 1977 - 298-Child 260-Child
The abusive p a t t e r n consists of three factors: the abusive p a r e n t or guardian; the abused child, and the t r i g g e r i n g event. G r e e n 6 h a s a d d e d a fourth factor, c u l t u r a l tolerance. The profile of the abusing p a r e n t consists of att r i b u t e s which have been acquired over a lifetime. The p a r e n t s of abused children m a y t h e m s e l v e s have been abused, neglected, or i n a p p r o p r i a t e l y m o t h e r e d d u r i n g childhood. The individual who h a s no realistic way of h a n d l i n g the problems of his or her children m a y fall into a p a t t e r n of child abuse. Often an abusive p a r e n t possesses low self esteem while at the same t i m e he or she d e m a n d s u n r e a l i s t i c a l l y h i g h performance of the child. The p a r e n t is u s u a l l y incapable of responding to the basic needs of the child, and, in fact, m a y desire support from the child, r a t h e r t h a n the reverse. Often, the p a r e n t d e m o n s t r a t e s gross inconsistencies in his or h e r r e l a t i o n s h i p w i t h the child. This inconsistency m a y v a r y from a lack of d e m o n s t r a t i v e n e s s to emotional over-involvement, and m a y range from l a x i t y to e x t r e m e physical p u n i s h m e n t , s The spouse m a y be unsupportive, or m a y p l a y a passive role by i g n o r i n g abusive behavior in his or h e r mate. The child a t risk for abuse or neglect is the child who is perceived as d e m a n d i n g or difficult to satisfy by the a b u s i n g parent, a l t h o u g h in fact he m a y be no different from other children. The p r e m a t u r e infant, the u n w a n t e d or i l l e g i t i m a t e child, the r e t a r d e d or h y p e r k i n e t i c child, is more likely to be abused. The colicky infant, who feeds poorly and cries often, can produce severe stress in a h i g h - r i s k parent. B a t t e r i n g is more likely when a child is sick. The t r i g g e r i n g crisis is a p r e c i p i t a t i n g event, e i t h e r major or minor, in t h e r i g h t setting. Occurrences such as a death, divorce, loss of a job, or even a b r o k e n television set, can be the t r i g g e r i n g event. A fourth factor, c u l t u r a l tolerance, ~ can be import a n t if the c o m m u n i t y accepts corporal p u n i s h m e n t as a l e g i t i m a t e form of discipline.
Abuse, Neglect
abuse will probably n e v e r be known, the reported figures are probably fairly reliable in centers with an active child abuse education program. In the U n i t e d States, about 10% of injuries seen in children under three y e a r s of age are nonaccidental. 6 About 30% of fractures in children under two are the r e s u l t of abuse. ~ It is e s t i m a t e d t h a t of t h e child victims of physical abuse, one t h i r d are u n d e r the age of 6 months; one t h i r d are between 6 months and 3 y e a r s of age, and one t h i r d a r e over 3 y e a r s of age. In m y experience, p r e m a t u r e infants and step-children a p p e a r to be at g r e a t e r risk for abuse. More m a l e s t h a n females are physically abused, although sexual abuse is more common in females. ~ A b u s i n g p a r e n t s come from all social s t r a t a . Women are more often involved in child abuse t h a n men, a l t h o u g h when fathers are unemployed and at home, t h e y a p p e a r to inflict child abuse to the same degree as the mothers. Men t e n d to inflict more serious injury. In m y experience, the m a j o r i t y of a b u s i n g parents are married, of average intelligence, and between 20 to 35 y e a r s of age. CATEGORIES OF ABUSE Child b a t t e r i n g m a y involve physical or s e x u a l abuse, n u t r i t i o n a l or m e d i c a l neglect, or e m o t i o n a l abuse. Physical abuse consists of the infliction of inj u r i e s such as bruises, fractures, and burns. Three special injuries t h a t should raise a strong suspicion of batt e r i n g are u n e x p l a i n e d fractures, s u b d u r a l h e m a t o m a s , and r u p t u r e d a b d o m i n a l viscera. The real incidence of sexual abuse in c h i l d r e n is unknown, since most children will conceal such incidents, f e a r i n g social rejection or further abuse. G e n i t a l or p e r i n e a l injuries m a y be a result of sexual abuse. This a r e a deserves s e p a r a t e discussion, a n d will not be covered in today's talk. N u t r i t i o n a l d e p r i v a t i o n m a y be the cause of failure to thrive in a small n u m b e r of children. Neglect of medical care is a subtle form of abuse. E x a m p l e s of this include an a s t h m a t i c child who is not given his bronchodilators, or a diabetic not given his insulin. Court orders to hospitalize and t r e a t children are occasionally needed in s i t u a t i o n s which the p a r e n t s do not acknowledge or recognize as l i f e - t h r e a t e n i n g emergencies, such as the need for blood transfusions, or the necessity to hospitalize a child w i t h meningitis. E m o t i o n a l abuse is e x t r e m e l y difficult to diagnose and treat. While the pain of p h y s i c a l abuse m a y fade away, the d a m a g e done to a child's psyche from h a v i n g been locked in a closet, chained to a bed, or being called a s4/111
DIAGNOSIS OF CHILD ABUSE The physician's role in child abuse consists of the recognition a n d t r e a t m e n t of the abused child, and the r e p o r t i n g of suspected abuse or neglect to the appropriate agencies. One m u s t t h i n k of the possibility of abuse in order to recognize it. A h i g h index of suspicion, coupled with an organized clinical approach, is necess a r y for the detection of inflicted injuries. The emergency p h y s i c i a n plays a major role in the recognition, t r e a t m e n t , and even the p r e v e n t i o n of child abuse, since most often the child is t a k e n to a n emergency departm e n t for t r e a t m e n t . A p h y s i c i a n m a y have only one chance at the diagnosis, since frequently the abused child is t a k e n to a different hospital for each episode. The abused child m a y exhibit a characteristic vac a n t or unresponsive facies d u r i n g the e x a m i n a t i o n . In particular, children of 3 to 5 y e a r s of age m a y be abnorm a l l y well-behaved - - they'd b e t t e r be, for t h e i r lives m a y depend on it. Other c h a r a c t e r i s t i c s of the abused child include a wariness of physical contact w i t h adults. The child m a y not look to the p a r e n t for reassurance, or m a y cry helplessly d u r i n g the e x a m i n a t i o n 2 The p a r e n t ' s b e h a v i o r m a y be e q u a l l y inappro-
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d u n k i n g type injury of the buttocks is suggested by the absence of b u r n s on the back and posterior thighs. B l u n t t r a u m a to the nose may result in the "pugilistic puss" - - broadening of the nose, with deviation of the nasal septum due to cartilaginous injury or h e m a t o m a formation. Along with n a s a l t r a u m a , there m a y be associated injuries each as bruised or lacerated lips, broken teeth, a n d periorbital, facial, or ear hematomas. Forced feeding is another form of abuse, and can result in b r u i s i n g or laceration of the lips or tongue. A blow to the ear m a y r u p t u r e the t y m p a n i c membrane. Multiple skeletal injuries, w h e t h e r old or new, suggest inflicted injury. A spiral fracture of a long bone may be produced by forceful twisting of the extremity. Children who cannot walk are u n l i k e l y to incur such an injury accidentally. Metaphyseal fraying can be produced by twisting t r a u m a . The firm periosteal attachm e n t at the metaphysis is broken offas a chip fracture. 9 B l u n t s k e l e t a l t r a u m a can produce s u b p e r i o s t e a l hemorrhage, which leads to periosteal elevation and e v e n t u a l subperiosteal calcification. 5 Cupping at the ends of long bones, especially the femur, is suggestive of nonaccidental injury. 12 Violent shaking can produce a subdural h e m a t o m a if i n t r a c r a n i a l bridging veins are lacerated or torn, and funduscopic e x a m i n a t i o n may demonstrate r e t i n a l hemorrhages. 11 Rib fractures, u s u a l l y m u l t i p l e a n d i n various stages of healing, may result from b l u n t injury to the chest. Abdominal injury is a common cause of death in battered children. Blows to the abdomen can cause contusion or r u p t u r e of the viscera, especially the liver, or can result in a pancreatic pseudocyst. In the child with suspected abuse, a skeletal survey should always be performed. If there are m u l t i p l e bruises, or a history of easy bruising, a coagulation survey should be obtained. Color photographs should be t a k e n to document any physical findings.
priate. He or she may display little or no response to the crying child, and may seldom touch or look at him. A suspicion of abuse should arise if the p a r e n t cannot explain the history of the accident satisfactorily. In one child I treated, a skull fracture in a two-month-old inrant was explained by the i n f a n t rolling off the couch onto a carpeted floor. The p a r e n t may present contradictory histories on separate occasions, or may be reluctant to provide information regarding the injury. He or she may display anger at being questioned, may be angry with the child for being hurt, may exhibit little concern about the injury, or may show overconcern. There may be a prolonged interval between the occurrence of injury and the visit for t r e a t m e n t . Occasionally, a n abusive p a r e n t may fail to visit the child d u r i n g hospitalization, or may disappear immediately after the child's admission. The presence of multiple injuries involving various body surfaces, often in various stages of healing, should arouse the suspicion of abuse. In one series of autopsies performed on battered children, 50% of the deaths were due to a subdural hematoma, and 25% were due to a ruptured viscus. 7 About 10% of b u r n s in children are secondary to abuse. 9 Clinical findings suggestive of abuse are failure to thrive, perioral injuries, fractures in a child u n d e r age 3, frequent injuries, old healed fractures on x-ray films bizarre injuries, advanced u n t r e a t e d disease, genital or perianal t r a u m a , clearly demarcated burns, subdural hematomas, skull fractures, or ruptured viscus. ~ U n c o m m o n manifestations of nonaccidental injury include isolated r e t i n a l hemorrhages, s u b g a l e a l hematomas due to h a i r pulling, h a n d p r i n t bruises, h u m a n bites, i n t r a m u r a l h e m a t o m a s of the bowel, pancreatic pseudocysts, h y p e r n a t r e m i c dehydration in a n older child, or repeated overdose with tranquilizers2 ° On physical examination, the presence of certain types of injuries should raise a suspicion of inflicted injury. Bruises on a n i n f a n t who is totally dependent on others for care m e a n s inflicted injury, whereas this is not necessarily true of b r u i s i n g in a n older child. If the child is struck or beaten with a hard object, such as a belt buckle, or hand, the i m p r i n t of the object is generally left on the skin. Flexible objects such as belts, whips, or cords generally leave a sharp line of demarcation between injured and n o n i n j u r e d skin. Restraints applied to the ankles or wrists leave circumferential bruises or abrasions. Bruises at the corners of the m o u t h may be due to gags. H u m a n bite m a r k s are characterized by a distinctive crescent shape. The bite made by a child will have a narrow arch, while a n adult impression will be left by molar teeth. Dogs and other carnivores generally tear the flesh, whereas h u m a n bites compress the flesh resulting in contusion. Burns, w h e t h e r accidental or inflicted, are common childhoo~'injuries. Most accidental b u r n s occur d u r i n g the ages of 18 months to 5 years. The physician m u s t consider the age of the child and the location and severity of the b u r n in relation to the history, in order to establish the etiology. Cigarette or lighter b u r n s on the palms, soles, or buttocks, are common inflicted injuries. A fresh b u r n should be differentiated from bullous impetigo. One child I saw had wrist b u r n s produced by his mother, as a p u n i s h m e n t for repeatedly t u r n i n g on the gas jets of the stove. Inflicted scalding burns, often produced by i m m e r s i n g the child's buttocks, hands, or feet in hot water, are suggested by distinct b u r n margins. A
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LEGAL OBLIGATIONS Since 1963, the laws of every state mandate the reporting of child abuse. Laws vary from state to state, often with little uniformity regarding the i n d i v i d u a l s responsible for reporting and the ultimate responsibility for investigation and m a n a g e m e n t . Q u e s t i o n : Who can report child abuse, and is it a legal obligation? Dr. ( ] r o v e r : In Michigan, child abuse and neglect m u s t be reported by any professional involved with the child, such as the physician, coroner, school nurse or counselor, or law enforcement officer. In addition, any individual, including a n o t h e r child, can report suspected abuse or neglect. Most cases of abuse or neglect are filed by hospital personnel. If it is reported from outside the hospital, the child is generally brought to the hospital for court evaluation. In Michigan, a person required to report a n episode who fails to do so is civilly liable for any damages resulting from the failure to report the incident. The physician must notify the parents t h a t the incident will be reported, and t h a t they will be contacfed by the local child welfare agency. He can state t h a t this is being done out of concern for the child. If the physician has difficulty facing the family, he can also state that he is obligated to follow his course of action under the law. It is best to be honest and straightforward with the parents. The physician should m a i n t a i n a concerned, n o n j u d g m e n t a l , n o n a c c u s a t o r y a t t i t u d e toward the family. If he is u n s u r e of the diagnosis, consultation
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an effective force in stirring the c o m m u n i t y and its agencies to give these children a n d their families the care they need.
should be sought. In general, the child should be hospitalized unless t h e physician has strong feelings t h a t the child can be safely treated and evaluated in the home. Q u e s t i o n : Why are physicians r e l u c t a n t to report child abuse? Dr. G r o v e r : There are m a n y reasons. The physician may not comprehend that the injury is the result of abuse. He may s h u n personal involvement, he may fear t h a t medical confidentiality will be broken, or he may fear a negative economic effect on his practice. He may even agree with the philosophy of physical punishment. s In 1972, a California court 7 awarded $600,000 to a battered child because the physician and hospital failed to report a n incident of abuse, and the child e v e n t u a l l y suffered serious injury. If anything, this type of legal and financial persuasion should encourage physicians to comply with the law. Q u e s t i o n : W h a t do you do if the family refuses to have photographs t a k e n of the child, or if they refuse hospitalization? Dr. G r o v e r : In t h a t case, our hospital may keep the child in protective custody, and a court order is obtained, usually w i t h i n several hours, to allow the professionals to proceed in the interests of the child. In large as well as small communities, the resources for the counselling of abused children and their families are generally sorely lacking. There are no simple remedies to this multifaceted problem. The b e g i n n i n g of the solution often lies with the phyaician. The recognition and appropriate medical m a n a g e m e n t of inflicted injury, and the reporting of such incidents to the appropriate agency, are the i n i t i a l steps. Court appearances will most often be necessary a n d the child's lawyer will need the full cooperation of the physician because the evidence of abuse is almost always circumstantial. In addition, the physician may find t h a t he himself can be
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REFERENCES 1. Radbill S: A history of child abuse and infanticide, i~ Helfer RE and Kempe CH. (eds): The Batterec7 Child. Chicago, University of Chicago Press, 1968. 2. Caffey J: Multiple fractures in long bones of infants suffering from chronic subdural hematoma. A m J Roentgenol R a d i u m Ther Nucl Med 56:163, 1946. 3. Silverman FN: Roentgen manifestations of unrecognized skeletal trauma in infants. A m J Roentgenol R a d i u m Ther Nucl Med 69-'413, 1953. 4. Wooley PV, Evans WA Jr: Significance of skeletal lesions in infants resembling those of traumatic origin. J A M A 158:539, 1955. 5. Kempe CH, Silverman FN, Steele BF, et al: The battered child syndrome. J A M A 181"17, 1962. 6. Green FC: Child abuse and neglect. Pediatr Clin North A m 22:329-339, 1975.
7. Brown RH: The battered child syndrome. J Forensic Sci 21:65-70, June 1976. 8. Smith SM, Hanson R: Interpersonal relationships and child-rearing practices in 214 parents of battered children. B r J Psychol 127:513-25, 1975. 9. Starbuck GW: The recognition and early management of child abuse. Pediatr A n n 5:146-154, 1976. 10. Kempe CH: Uncommon manifestations of the battered child syndrome. A m J Dis Child 129:12~5-126% November 1975. 11. Caffey J: Whiplash shaken infant syndrome. Pediatrics 54:396-403, 1974. 12. Caffey J: The parent-infant traumatic stress syndrome. A m J Roentgenol R a d i u m Ther N u c l Med 114:218-229, 1972.
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