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Diagnosing V61.21 Physical Abuse of Child
Recognizing When a Child's Injury or Illness is Caused by Abuse

Test | Table of Contents

Investigators must determine whether the explanation for an injury is believable. Police should begin their investigation by asking the caretaker for an explanation of the child’s bruises or injuries. This is best done by asking the question: How did the accident happen?
All bruises must be investigated. If bruises are found on two or more planes of a child’s body, investigators should be even more suspicious.

For example, a child has bruises on his buttocks and stomach. The caretaker’s explanation is that the child fell backward in the living room of the family home. This might explain the bruises on the buttocks, but not the stomach bruises. If a discrepancy exists between the reported cause of an injury and the injuries seen, law enforcement personnel should investigate further.

They should also keep in mind the following points:
- All other children in the home should be examined for possible signs of child abuse.
- Victims of physical abuse often have been intimidated and will usually support the abuser’s version of how their injuries
occurred to avoid further injury. They also feel that the abuse was just punishment because they were bad.
- A physical examination of the child in suspected cases of maltreatment must be done and the data recorded precisely.
- Laboratory data should be obtained to support or refute the evidence of abuse.
- If the reported history of an injury or injuries changes during the course of an investigation, or if there is conflict between two adult caretakers as to the cause of injury, the likelihood of child maltreatment increases.
- The demeanor of the child’s parents or caretakers is sometimes revealing. For example, the mother’s assessment of her pregnancy, labor, and delivery will often provide an insight into her attitude about her child as well as give an indication of whether there is something about the child that is influencing her behavior.

- Investigators should ask questions in an unobtrusive manner; for example:
• Was this a planned pregnancy?
• Did you want the baby?
• Do you like the baby?
• How did the accident happen?
• What were you doing just before the accident?
• Who was at home at the time of the accident?
• What do you feed the baby? How often? Who feeds the baby?

- Information about a child’s birth and his or her neonatal and medical history are critical elements in investigations. Hospital records can confirm or eliminate the existence of birth injuries.
- Any child may be abused, and child abuse occurs in all levels of society. However, there are some factors that increase a child’s risk of abuse. These include:
• Premature birth or low birth weight.
• Being identified as “unusual” or perceived as “different” in terms of physical appearance or temperament.
• Having a variety of diseases or congenital abnormalities.
• Being physically, emotionally, or developmentally disabled (e.g., mentally retarded or learning disabled).
• Having a high level of motor activity, being fussy or irritable, or exhibiting behavior that is different from the parents’ expectations.
• Living in poverty or with families who are unemployed.
• Living in environments with substance abuse, high crime, and familial or community violence.

The following are provided to help law enforcement personnel determine which injuries and illnesses in children are likely to be the result of abuse. However, it is also very important for law enforcement to work closely with physicians to determine the nature of all injuries.

Repetitive Accidents
Multiple bruises, wounds, abrasions, or other skin lesions in varying states of healing may indicate repetitive physical assault. Such repetitive accidents or injuries may indicate that abuse is occurring. A careful examination of the circumstances and types of injuries and an assessment of the child and family should be carried out by a professional skilled in family dynamics, usually the social worker investigating a report of suspected abuse. However, a police officer from the juvenile division may in some circumstances be responsible for this, rather than a social worker.

Cutaneous (Skin) Injuries
The most common manifestations of non-accidentally inflicted injuries are skin injuries. Several characteristics help to distinguish non-accidental skin injuries from accidental ones, including their location and pattern, the presence of multiple lesions of different ages, and the failure of new lesions to appear after hospitalization. Law enforcement personnel should be sure to obtain a complete history of all injuries from the caretaker.

Bruises are due to the leakage of blood into the skin tissue that is produced by tissue damage from a direct blow or a crushing injury. Bruising is the earliest and most visible sign of child abuse. Early identification of bruises resulting from child abuse can allow for intervention and prevent further abuse.
Bruises seen in infants, especially on the face and buttocks, are more suspicious and should be considered non-accidental until proven otherwise. Injuries to children’s upper arms (caused by efforts to defend themselves), the trunk, the front of their thighs, the sides of their faces, their ears and neck, genitalia, stomach, and buttocks are also more likely to be associated with nonaccidental injuries. Injuries to their shins, hips, lower arms, forehead, hands, or the bony prominences (the spine, knees, nose, chin, or elbows) are more likely to signify accidental injury.
Age Dating of Bruises
It is important to determine the ages of bruises to see if their ages are consistent with the caretaker’s explanation of the times of injury. Age dating of bruises can often be determined by looking at the color of the bruise. The ages and colors of bruises may therefore show if more than one injury is present. Table 1 shows the ages associated with the colors of bruises.

Table 1
Determining the Age of a Bruise by Its Color

Red (swollen, tender): 0-2 days
Blue, purple: 2-5 days
Green: 5-7 days
Yellow: 7-10 days
Brown: 10-14 days
No further evidence of bruising: 2-4 weeks

For example, a 2-year-old boy, not toilet trained, has several yellow-to-brown bruises on his buttocks. The caretaker’s explanation for the bruises is that the child tripped in the hallway the day before and fell on his buttocks. This would be suspicious because:
- Children seldom bruise their buttocks in accidental falls.
- Bruises on the buttocks are in the primary target zone for non-accidental injury.
- The child’s diaper (whether disposable or cloth), plastic pants, and clothing would have afforded some protection to his buttocks.
- If the injuries causing the bruises were sustained the previous day, the bruises should be red to purple.

Another child might have both bright red and brown bruises. The caretaker maintains that all of the bruises were the result of a fall that day. However, the bright red color indicates fresh bruises, while the brown bruises are older. The caretaker’s explanation is, therefore, suspicious, and separate explanations must be obtained for each bruise.

Bruise Configurations
Bruises will sometimes have a specific configuration. This may enable law enforcement officers to determine whether bruises are accidental or non-accidental. One of the easiest ways to identify the weapon used to inflict bruises is to ask the caretaker: How were you punished as a child? The pattern of a skin lesion may suggest the type of instrument used.

Bruise or wound configurations from objects can be divided into two main categories: those from “fixed” objects, which can only strike one of the body’s planes at a time, and those from “wraparound” objects, which follow the contours of the body and strike more than one of the body’s planes. Hands can make either kind of bruise, depending on the size of the offender’s hands and the size of the child.

Examples of fixed and wraparound objects include:
- Fixed objects: coat hangers, handles, paddles.
- Wraparound objects: belts, closed-end (looped) cords, open-end cords. (Closed-end cords leave a bruise in parallel lines; open-end cords leave a bruise in a single line.)

Natural or Normal Bruising
Injuries inflicted by human hands, feet, or teeth or those inflicted by belts, ropes, electrical cords, knives, switches, gags, or other objects will often leave telltale marks (e.g., gags may leave down-turned lesions at the corners of the mouth). These marks may also help in the investigative process. For example, the size of bite marks may help to determine the biter’s approximate age; their shape may help identify whose teeth made the marks. In some cases, however, bruises are acquired innocently, through play and accidental falls, or when a child has a defect in his or her clotting mechanism.

For example, a baby is brought to the hospital with purple bruises on several body surfaces. The parents were unable to provide an explanation other than that the baby “bruised easily.” Blood tests later revealed that the baby was a hemophiliac; hemophilia is associated with bruising easily, due to blood clotting problems. There is usually a history of bruising easily in families with such inherited diseases.

Other incidents of “easy bruising” in children can be explainedby a low blood platelet count. Multiple bruises can occur in children with leukemia. Diseases causing easy bruising, however, are rare, and inflicted bruises are much more common. The medical diagnosis of clotting disorders requires blood tests and interpretation of those tests by qualified physicians. Therefore, law enforcement officers should try to determine if bruises are the result of an accident or due to physical abuse.

Police must also remember never to jump to conclusions and to make a complete investigation of all aspects of suspected child abuse. However, their first duty is to secure the safety of the child quickly.

Mongolian spots (a kind of birthmark) also resemble bruises but can be distinguished by their clear-cut margins, the fact that they do not fade, and their steel gray-blue color. Mongolian spots may be found anywhere on the body (but are typically found on the buttocks and lower back). In addition, they are commonly found in African Americans, Asians, and Hispanics. Investigators should await medical reports when investigating such marks.

As shown in table 2, certain characteristics of the history, location, or pattern of burns may indicate whether they were


Indications That Burns May Not Have Been Accidental
- The burns are attributed to siblings.
- An unrelated adult brings the child in for medical care.
- Accounts of the injury differ.
- Treatment is delayed for more than 24 hours.
- There is evidence of prior “accidents” or an absence of parental concern.
- The lesions are incompatible with the history.

- The burns are more likely to be found on the buttocks, in the anogenital region (the area between the legs, encompassing the genitals and anus), and on the ankles, wrists, palms, and soles.

- The burns have sharply defined edges. For example, in immersion burns, the line of immersion gives the appearance of a glove or stocking on the child’s hand or foot.
- The burns are full thickness (all of the skin, and possibly muscle and bone as well, is destroyed).
- The burns are symmetrical.
- The burns are older than the reported history indicates.
- The burns have been neglected or are infected.
- There are numerous lesions of various ages.
- The burn patterns conform to the shape of the implement used.
- The degree of the burns is uniform (usually indicating forced
contact with a hot, dry object), and they cover a large area.

Indications That Burns Are More Likely To Be Accidental
- The burns are usually found on the front of the body. They occur in locations reflecting the child’s motor activity, level of development, and the exposure of the child’s body to the burning agent.

- The burns are of multiple depths interspersed with unburned areas and are usually less severe (such as splash burns).
- The burns are of partial thickness; that is, only part of the skin has been damaged or destroyed.
- The burns are asymmetrical.
- Apparently only one traumatic event has occurred, because the skin injuries are all of the same age.

J.A. Bay’s exhaustive review of the world’s literature of reported cases of non-accidental poisoning as a form of child abuse identified certain agents that are commonly used by perpetrators (“Conditions Mistaken for Child Sexual Abuse,” in Reece, R.M. (ed.): Child Abuse: Medical Diagnosis and Management).

The most frequently used agents included barbiturates, psychoactive drugs, tranquilizers, insulin, ipecac, arsenic, laxatives, salt, water, alcohol, marijuana, and opiates. The children poisoned by such agents display a variety of presenting signs and symptoms, but nearly all have major changes in their mental status, ranging from irritability, listlessness, lethargy, stupor, and coma to convulsions.

The peak age for accidental poisoning is 2 to 3 years, and it is rare under the age of 1 or over the age of 6. The usual history of non-accidental poisoning is that either the ingestion was not witnessed or that it was administered by a sibling or another child. In addition, the history may change over time.

Head Injuries
Many fatalities from child abuse involve serious head injuries. Subdural hematomas due to child abuse are most common in children less than 24 months of age, with the peak incidence at about 6 months. The signs and symptoms of subdural hematomas may either be nonspecific, including irritability, lethargy, or a disinclination to eat, or there may be more classic signs of raised intracranial pressure such as vomiting, seizures, stupor, or coma.

A subdural hematoma associated with a skull fracture is due to a direct impact to the head and ordinarily leaves external marks. It may be associated with shaking the baby violently or with an extreme blow to the head, such as occurs when children are thrown against a hard object. Retinal hemorrhages strongly suggest whiplash or shaking as the origin of the injury.

The presence of bilateral subdural hematomas is also positively correlated with whiplash or shaking. Therefore, law enforcement personnel need to investigate whether these were non-accidental injuries. Hair pulling as a means of discipline may be responsible for hair loss or baldness (alopecia).

Eye Injuries
- External eye injuries are so common in children that they are seldom clear-cut evidence of abuse.
- Two black eyes seldom occur together accidentally.
- The “raccoon eyes” associated with accidental and non-accidental fractures at the base of the skull may look similar to each other, but raccoon eyes from non-accidental trauma usually are associated with more swelling and skin injury. The history helps distinguish between them.
- Hyphema, the traumatic entry of blood into the front chamber of the eye, may be the result of a nonaccidental injury caused by striking the eye with a hard object, such as a belt buckle. The child will complain of pain in the eye and have visual problems.
- Retinal hemorrhages are the hallmark of shaken baby syndrome and are only rarely associated with some other mechanism of injury.
- Non-accidental trauma must always be considered in a child under 3 years of age who has retinal hemorrhages or any traumatic disruption of the structures of the globe of the eye (e.g., the lens or retina) or the skin around the eye.

Investigator’s Checklist for Use in Suspected Cases of Physical Child Abuse
Far too often police investigating a child’s injuries will let their emotions interfere. It should be remembered that the child abuse investigation process, if performed correctly, will ultimately determine which injuries were non-accidental.

The following are some important questions and issues to be considered when investigating a suspected case of child abuse.
- Begin by asking questions about the child’s family history, substance abuse or other environmental factors in the home, and the parents’ marital status, employment history, or unrealistic expectations of the child.
- How could the child’s behavior or the caretaker’s stress have contributed to the crisis?
- Could the child do what the caretakers told you he or she did?
- Is the child a “target” child (a child perceived by the parent(s) as having negative characteristics), or are there target children present?
- Was there any delay in treatment or was hospital “shopping” involved?
- What are the locations, configurations, and distributions of the bruises, welts, lacerations, abrasions, or burns?
- Do the injuries appear to have been caused by the hands or an instrument? Can you determine what instrument might have been used?
- Are multiple injuries (in various stages of healing) present?
- Are the injuries within the primary target zone (the back, from the neck to the back of the knees and including the
shoulders and arms) and on more than one leading edge (the outside of the arm or leg, etc.) of the body?
- Can you determine the positions of the offender and the child during the attack?
- Is there any evidence of attempts to hold the child in a certain position or at a certain angle during the attack? Are there such control marks on the wrists, forearms, or biceps?
- Was a careful check made for injuries on the head, mouth, ears, and nose?
- Farley M.S., Robert Hugh, and Robert M. Reece M.D., “Recognizing When a Child’s Injury or Illness is Caused by Abuse”, U.S. Department of Justice, 2002,

There is no question for the Introduction
The next question is found in the next section, Section 3
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