The term "battered child" was popularized by C. H. Kempe,1 in 1962, who reported nonaccidental injuries sustained by children due to acts of parents or other adults reponsible for their care. Prior to that, other physicians such as Wooley and Evans,2 Caffey,1 and Silverman,4·5 described clinical and sociological features of child abuse, but it was Kempe who made both physicians and laymen aware that it was not only "abnormal parents" who abused children, but also "normal parents" who do not necessarily have psychopathic or sociopathic personalities or come from borderline socioeconomic groups. The incidence of abuse has increased since that time and child abuse is still often unrecognized. Since repeat abuse occurs in more than 20% of all children, often leading to permanent injury and death, only early recognition of child abuse will allow the interruption of the vicious cycle which may not only kill the involved child but siblings as well.
The physician not only has a moral, ethical and medical obligation to report suspected child abuse, but is legally mandated to do so. All states have reporting statutes which mandate certain professionals, such as physicians and nurses, to report suspected child abuse. The law provides that mandated persons making such a report in good faith shall have immunity from civil and criminal liability. Many physicians are not aware that the willful failure to report suspected child abuse is not only a Class A misdemeanor, but the physician is also civilly liable for any damages caused by the failure to report child abuse. It behooves each physician, therefore, to be familiar with pertinent state laws concerning child abuse. In general, an abused child is defined as one who is under 18 years of age whose parent or other person legally responsible for his or her care inflicts or allows to be inflicted physical injury, sexual offense, or creates or allows substantial risk to the child. A neglected child is a child under 18 years of age whose physical, mental or emotional condition has been impaired because of failure to supply the child with clothing, shelter, education, proper supervision or guardianship, or one who has been abandoned.
Despite the mandated report of child abuse, the actual incidence is not known, since it can safely be assumed that the vast majority of abused children will remain undiagnosed and unreported. Approximately 0.5 to 1 million children in the United States are assumed, however, to be either abused, sexually molested or severely neglected.6 Child abuse is assumed to be the greatest single cause of death in infants between 6 and 12 months of age.7 Between 1 and 6 months of age, child abuse is second as cause of death only to the sudden infant death syndrome.8 Many "SIDS" cases are now also assumed to be the result of child abuse rather than unexplained sudden infant death syndrome.9 Most of the 1,620 children killed in 1972 were murdered by their parents or caretakers.
DIAGNOSIS OF THE BATTERED CHILD SYNDROME
Battered child syndrome involves the abuser, stress and triggering crisis, the abused child, and the injury that is the final result. Certain characteristics of the abuser, either parent or guardian, should arouse suspicion. Identification of stress and the triggering crisis, which may have led to either a single outburst of violence or continued abuse, may explain a parental reaction or at least alert the examining physician. Examination of the abused child, correlating history, appearance, and behavior of the child, may give a clue to the cause of the injury. Finally, evaluation of the injury itself and its correlation with the alleged history may point to child abuse as the cause of the injury, rather than accident.
Profile of the Abuser
Young and immature parents may be unable to render the emotional and physical support required by their children. Unrealistic expectations, especially combined with a low parental intelligence, poor selfconcept, or unstable marital relationship, are frequently found in abusive parents. Parents who have themselves been abused are more likely to expose their children to a similar pattern of neglect and abuse. While psychopathic parents, especially those with chemical addiction, are particularly prone to abuse their children, it must be emphasized that even the most normal appearing parent, with what appears to be a stable socioeconomic background, may be either a single instance "baby basher" or a chronically abusive parent.
Identification of the stress under which a parent may labor, emotional, sociological or economic, may help the physician to identify the abusive parent and allow the institution of therapeutic measures which ultimately benefit the parent as well as the child. Cameron's description of the majority of battering parents10 as parents "who are more or less normal but worn out by their small children, especially under emotional or financial stress with no one to turn to for help," has remained valid. A close consultation with social services, psychiatrists, psychologists and other professionals, is essential for the diagnosis and treatment of the abused child and his or her parents.
The Triggering Crisis
Various forms of stress, socioeconomic, parent or child produced, can predispose the parent to overreact so that even a minor annoyance can lead to a major crisis.11 Within certain social and cultural groups, stress may not only predispose members to child abuse, but also lead to injuries which may be quite typical for the particular groups.12
The Abused Child
Just as completely "normal" parents may be potential child abusers, the "normal" child can also trigger a crisis or become the unrelated target of the parent's anger. Predisposing factors do exist, however, which may make a child more vulnerable. These include unwanted, illegitimate, or difficult children. Chronic illnesses, prematurity, congenital defects and retardation are foremost among conditions predisposing to abuse. What may appear to be a minor problem to the well-balanced parent, such as occasional soiling, can trigger a violent crisis, especially in the predisposed parent or guardian.
The recognition of child abuse is based on the same diagnostic principles valid for all medical problems: a precise history, with particular attention to the reliability of the historian, followed by a thorough physical examination, backed up by appropriate laboratory and x-ray studies.
A detailed family history, including past medical problems, the health and whereabouts of other siblings, and socioeconomic conditions are essential in the evaluation of a child suspected of having been abused. The inability to obtain an accurate history, intentional withholding, or presentation of a false history can make the recognition of child abuse diffi' cult. Careful assessment of both history and historian is, therefore, essential. The parent's behavior may give the first clue: lack of cooperation, inappropriate reaction, expression of guilt or fear, behavior problems, signs of addiction, or obvious tension and hostility between parents. The history given by the parent can change with different examiners, may vary or be incompatible with the child's problem. Not infrequently, parents emphasize unimportant or totally unrelated minor problems. An inordinate delay between injuries and office visits, multiple visits at various institutions or offices, especially at unusual hours, are also quite suggestive of child abuse. Separate interviews with parents or guardians, and simple repetitive interviews may reveal contradictory statements. Kempe warned many years ago that a parent bringing a well baby to the emergency room several times, without apparent cause, may be trying to warn the physician that they themselves are afraid they might harm the child.
The physical examination of the suspected abused child must be at least as thorough as the examination of an accidentally injured child. Signs of passive neglect must be evaluated, such as the child's state of cleanliness, clothing, general appearance, nutritional status, growth and development, and behavior. While the chronically abused child may exhibit typical whimpering obethence, tolerating both physical examination and painful episodes such as blood drawing with pitiful compliance, a normal response can also occur and even the grossly abused child may cling to the abusive parent rather than cooperate with the examining physician or nurse. The child must be totally undressed for the physical examination and the entire body must be inspected, including all orifices. Skin lesions, especially if in various stages of healing, or involving various parts of the body, suggest abuse. Scars due to unusual injuries such as whipping with electric cords, belts, belt buckles, can openers, or burns are indicative of child abuse. Bite marks, grab marks, evidence of venereal lesions such as condyloma acuminatum, or general injuries obviously indicate abuse. Not only signs of recent injuries, but also healed scars, their distribution, and most likely cause should be evaluated. The remainder of the physical examination follows the same rules which apply for a normal physical examination: particular emphasis on the examination of both boys' and girls' genitalia and anorectal region.
In children with multiple skin bruises a baseline coagulation profile and hematological workup should be included. The remainder of the laboratory workup is based on the suspected underlying injuries.
In all children suspected of having been abused, a skeletal review is mandated by most state laws, since a skeletal review is the most reliable indicator of chronic child abuse. Additional radiological examination will depend on the underlying injury and may include bone scan, computerized axial tomography, contrast studies, nuclear scan or NMR studies.
Thirty-five percent of all injuries involve the trunk and arms, 33% head and neck, and 33% the lower body. The skin lesions which are most characteristic of child abuse include bruises, ecchymosis and lacerations in various stages of healing, involvement of different parts of the body or bilateral presence. Instruments like lamp cords, ropes, belts, and belt buckles leave characteristic scars. A combination of skin bruises and penetrating injuries caused by tools like knives, ice picks, or can openers are characteristic. The location of skin lesions may be suggestive. Small children who fall sustain accidental injuries usually only at the anterior body surface; posterior marks are usually due to abuse. Finger bruises, especially in combination with other injuries, can be suggestive. They can consist of grab marks, encirclement bruises or choke marks. Discoloration of a skin bruise may give a clue to the time of injury. Fresh bruises are usually reddish purple, after 3 days the color changes to a yellowish green, and after 1 week the bruises usually have a yellowish brown discoloration.11 Other causes which can lead to bruises in various stages of healing, difficult to differentiate from child abuse, include diseases such as hemophilia, anaphylactoid purpura, Von Willebrand's disease, and Ehlers-Danlos syntitorae.
Following the trunk and arms, the foce is the most common site for injuries due to child abuee. Abrasions, such as bruises and lacerations are followed by more serious injuries such as nasal septal injuries or fractures, or loss of teeth. A tearofthefrenulumanda separation of the upper lip from the gingiva is characteristic of a blow or forced feeding. Scalp injuries may be the result of beatings (such as belt buckle injuries), secondary to falls, or due to the pulling of hair. Bilateral periorbital bruising is characteristic of slapping or punching, which can also lead to conjunctival or subconjunctival hemorrhages. Dislocation of the lens, retinal detachment, or hyphema can also occur. Optical atrophy, on the other hand, is a late sequelae of intercerebral injury.
Central nervous system damage is estimated to be present in 20% of battered children. It has remained one of the main causes of death, especially in children under 2 years of age, since the infant's brain is particularly vulnerable to injury. The mechanical forces leading to central nervous damage can be translocational or rotational. Translocational forces are due to a direct impact; rotational are due to sudden acceleration or deceleration. Manual shaking, which can lead to the "shaking baby syndrome," can lead to major CNS injury and death, especially in an infant under 15 months.13 Clinical signs include irritability, lethargy, seizures, decreased muscle tone or respiratory problems. Associated retinal hemorrhages are not uncommon, nor is a bulging of the anterior fontanelle. A CT scan is usually diagnostic for subdural hemorrhage, cerebral contusions, or subarachnoid hemorrhage. Subdural hemorrhage has remained the most common intracranial lesion resulting from venous tears secondary to abuse. Cerebral hygromas, especially in association with long bone fractures, are also diagnostic for child abuse.
The peculiarities of the growing bone and the injuries sustained by these children can lead to characteristic findings suggestive of abuse. Torsion, wrenching, pulling, and shaking can lead to epiphyseal and metaphyseal fractures and separations. The associated subperiosteal hemorrhages lead to calcification, also quite typical. Radiological changes may become apparent within I to 2 weeks following an injury; sometimes a bone scan may even show earlier changes. Transverse midshaft fractures, while more common in abused children than spiral fractures, can also be secondary to accidental injuries. Spiral fractures, on the other hand, are more suggestive of child abuse. Distal clavicular fractures are common in abused children. Due to the elasticity of the rib cage, rib fractures are rare even in children with major thoracic injuries. Posterior rib fractures, adjacent to the costal vertebral junction, are particularly suggestive of child abuse in contrast to lateral rib fractures, which are more likely due to accidental thoracic compression or resuscitation.
Other radiological clues to child abuse include fractures in various stages of healing, the combination of epiphyseal and metaphyseal fractures, multiple or bilateral injuries, spiral fractures of long bones, distal clavicular fractures, posterior rib fractures, or a combination of visceral or CNS trauma and fractures.
Conditions which may mimic accidental and nonaccidental fractures include obstetrical trauma, nutritional or metabolic deficiencies, skeletal dysplasias, scurvy, rickets, secondary hyperparathyroidism, and Vitamin A intoxication.
The clinical findings of tntra-abdominal trauma due to abuse are indistinguishable from those caused by accidental trauma. The causes of intra-abdominal trauma vary, however, and sometimes can be differentiated at operation. The "decelerating" force of a punch, kick or blow to the abdomen leads to shearing of tissues in the midepigastrium between the deceleration force and the vertebral bodies, most likely leading to a rupture or hemorrhage of the duodenum, proximal jejunum, mesentery, pancreas or ietioperitoneum. The decelerating force of a punch leads to a tear of the mesentery or intestine at the site of the ligamental support. Compressing forces, seen in accidental injuries, are more likely to produce intestinal injuries on the antimesentery border. Spleen, liver, intestine, and pancreas are most commonly injured in child abuse.11,14,15
Not all intra-abdominal injuries will result in apparent clinical signs and symptoms requiring operative intervention. Only with the advent of computerized scanning have intrahepatíc, splenic, pancreatic, and renal injuries been documented, which prior to the onset of advanced imaging were often not recognized.
The diagnostic workup and treatment of intraabdominal injury in the battered child is identical to that of the accidentally injured child.
At least one third to one half of all bums sustained by young children are the result of either passive neglect or intentional injury.16,17 Approximately 5% of all reported abuse cases are due to bums, which include splash bums, contact bums and flame bums. 12 Seventy percent of scalding bums occur in children under 4 years of age, 41% under the 1 year age group Contact burns, involving either a hot iron, grid, radiator, or heater, are most likely to involve children between the ages of 1 and 3 years. A discrepancy between the history and the findings at examination should alert the physician to the possibility that the bum may be induced rather than accidental. A child, supposed to have sustained a splash burn, is unlikely to have deep 2° burns with flexion sparing of extremities, stocking-like sharp demarcations, or bums over the back.
The frequency of sexual child abuse has only become apparent in the last decade with a sharp increase in. the reports by the lay press and the medical literature. Up to 20 million Americans are assumed to have been involved in an incestuous sexual relationship at some point in their lives. 18 One of every four girls and one of every ten boys is assumed to have been sexually abused before the age of 16. Although strangers are responsible for some cases, approximately 75% of sexually abused children are molested by a family member or a friend of the family. Of 56,900 children reported to be abused in 1984 in New York City, 3,189 were suspected of having been abused sexually. Sexual abuse in New York state has increased from less than 1% to over 5% within the last 10 years. 19 The true incidence is probably far greater than reported.
The sexually abused male is usually younger than the sexually abused female, with an average of 8 years for the male and 10 years for the female.20 Sexual abuse, however, can also occur in infancy and, in our own experience, female infants under the age of 2 years were chronically abused and had adult sized vaginas.
On physical examination, the sexually abused child may show evidence of multiple injuries, including bruises, ecchymosis, grab marks or evidence of perineal, perianal, vaginal or penile injury. Evidence of inflammation, venereal disease, and acute or chronic signs of vaginal or rectal penetration are diagnostic. The physical examination of the alleged sexually abused child must follow individual state laws. "Rape kits" with detailed instructions are available in each state. Photographic documentation is also required in most states. Examination must include oropharynx, external genitalia, perineum, vulva, vagina, hymenal ring and rectum. Examination should include smears for sperm, semen, and venereal disease. Scalp hair, pubic hair, and fingernail scrapings must be included in the rape kit.
Evidence of venereal disease, even in the absence of abuse, must be reported to appropriate authorities in children under 16 years of age.
Behavioral manifestations of the sexually abused child depend on whether or not the abuse consists of an acute single episode or whether it is due to chronic abuse.
The examination of the sexually abused child should not constitute a second rape! Patience, understanding, and sedation are required to avoid additional injury to the already abused and frightened child.
While most sexual abuse injuries are easy to diagnose, accidental injuries can mimic "rape injuries," in particular, straddle injuries. The latter are usually limited to the perineum, often without vaginal pentration. Impalement injuries are penetrating but are not accompanied by the telltale marks such as grab marks.
A common medical condition confused with abuse is urethral prolapse, which usually occurs in black girls between the ages of 2 and 4 years. The presence of a urethral opening in a dark, prolapsing, grape-like, sometimes hemorrhagic mass, should allow an easy diagnosis distinguishing prolapse from injury.
PREVENTION AND TREATMENT
The treatment of physical injuries sustained due to abuse is no different from treatment for accidental trauma. Much more attention must be paid, however, to the psychological trauma sustained and the prevention of repetitive trauma. In most instances, not only the child, but also the parent, will need help. While major or chronic abuse, especially with addicted parents, may be incompatible with a reunion of child and family, in many instances a thorough investigation of the socioeconomic and psychological problems of the family may lead to appropriate help, preventing further abuse of the child, and even allowing the reconstitution of the family. The physician has to be aware of his obligations; he must not only diagnose and treat the abused child, but he also has an obligation to initiate efforts which may provide needed assistance to the entire family, including the abusive parent.
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