Injuries and Behaviors Indicative of Abuse

• Physical Abuse: Signs and Symptoms
• Sexual Abuse: Signs and Symptoms
• Emotional Abuse: Signs and Symptoms
• Neglect: Signs and Symptoms

- Unsuspected fractures “accidentally” discovered in the course of an examination (sometimes a routine examination).
- Injuries inconsistent with, or out of proportion to the history provided or with the child’s age/developmental stage.
- Multiple fractures, often symmetrical, or fractures at different stages of healing; any fractures in nonambulatory children are suspicious.
- Skeletal trauma combined with other types of injuries, such as burns.
- Subdural hematoma.
- Failure to thrive - the child may appear malnourished, chronically underweight, or be losing weight.

- Caused by pinching or hitting the child with a hand or with an object.
- Bruises go through an evolution of color: initially - red, violet, black, or blue; later - brown, green, or yellow. The color is affected by the depth and location of the bruises as well as surrounding light and skin color. Estimating the age of a bruise by its color cannot be done with much precision:

- A bruise with any yellow is usually older than 18 hours - Red, blue, and purple/black may occur anytime from 1 hour of bruising to resolution - Red can be present no matter what the age of the bruise - Bruises of identical age and cause on the same person may not appear as the same color and may not change at the same rate

- Bruise sites: neither the ears or buttocks are injured frequently in accidents; bruises on knees, shins, foreheads, and elbows may be either intentional or nonintentional.
- Pinch bruises: often symmetrical pattern (i.e. on each earlobe).
- Loop or belt marks: caused by whipping the child with a looped cord (i.e. an electrical cord) or belt; no disease or accident looks like a loop or belt mark.
- Ligature bruises: may be caused by ropes tied around the child’s ankles or neck, resulting in a bruise or a burn.
- Slap marks: fingers may leave bruises on the face.
- Loose tissue with little bony structure underneath (i.e. eyelids, genitals) bruise most easily and retain bruises longest.
- Genital bruises: be suspicious if a caretaker delays seeking treatment for a child with a genital injury. Injury may be caused by pinching a boy’s penis to punish him for touching himself or using a string or rubber band around the penis (causing grooves) to prevent the child from wetting the bed. Bruises in the inner thigh or genital area may indicate sexual abuse.
- Note that Mongolian spots (birthmarks) may be mistaken for abuse - these are usually grayish-blue, clearly defined spots on the buttocks, back, or extremities, and are most common in African American and American Indian babies.

- Occur on soft tissue areas such as abdomen, throat, buttocks, and thighs.
- Injuries to buttocks, lower back, or thighs can be caused by whipping.
- Some areas of the body are normally protected by being inside or covered by other body parts (i.e. medial aspects of extremities); it would be difficult to fall and injure these areas.
- Lacerations of the ear, nose, or throat do not tend to occur accidentally and should arouse suspicion.
- A torn frenulum of the upper lip, especially in an infant, is very concerning for abuse in the absence of a plausible history.

- Determine if bite marks are human or animal: torn flesh is usually a dog bite; compressed flesh is usually a human bite.
- If the wound is fresh, swab for possible recovery of the offender’s saliva for DNA evidence.
- Human bites appear as distinctive oval to horseshoe-shaped marks in which tooth impressions appear as bruises facing each other.
- If the distance between the canines is >3cm, the bite is most likely from a human adult. Adult bite marks are a sign of serious danger to a child - uncontrolled aggression.
- Victim’s teeth should be examined and measured to exclude the possibility of a self-inflicted bite.
- A forensic odontologist or pathologist should evaluate the size, countour, and color(s) of the bite marks, as well as make molds of a suspected abuser’s teeth and possibly of the bite itself since each individual has a characteristic bite pattern.

Download the Checklist for Use in Suspected Cases of Deliberate Burn Injuries of Children

- Burns from hot water are the most common whether abusive or nonintentional.
- Accidental burns tend to be asymmetrical in distribution.
- A burn covering >20% of the body is severe regardless of the child’s age; a burn covering >65% of the body can be fatal, even if it is a first degree burn.
- Medical conditions mistaken for burns include scalded skin syndrome (caused by staph), impetigo, and severe diaper rash.
- Immersion burns: have a “water line” or sharp demarcation border; document the absence of splash marks - symmetric burns with sharp edges are very suspicious.
- Doughnut hole burns: caused when a child is forced into a bathtub; parts of the body, usually the buttocks, rest on the bottom of the tub and thus will not burn, creating a patch of unburned skin in the center of the burn (like a doughnut hole).
- Dunking burns: caused by dunking the child into scalding water (often as punishment for wetting the bed); hands and feet are not burned since the child is held and dunked; sharp demarcations - often called “parallel lines”- since the child is held but not forced to the bottom of a tub or pot on the stove (so no doughnut burn); document the absence of splash marks.
- Stocking or glove burns: caused by immersing the child’s hands or feet in hot water or holding the hands or feet under very hot running water; usually shows sharp demarcation.
- Splash burns: caused by the offender throwing hot liquid at the child. Nonintentional splash burns are usually on the head or top of the chest and run downward (may be caused by a child reaching upward to grab a pot handle). Liquids thrown at a child hit at a horizontal angle, so the burns will be concentrated on the child’s face or chest, and will run toward the back of the body. Splash burns on the back or buttocks are highly suspicious.
- Cigarette burns: usually appear on the trunk, external genitalia, or extremities - often the palms of the hands or soles of the feet; usually symmetrical in shape (impetigo blisters are irregular and can be ruled out by testing for signs of strep); often multiple burns in various stages of healing.
- Chemical burns: caused by household products. Some parents or caretakers force children to drink lye derivatives (toilet bowl cleaner, detergents, or oils), causing chemical burns of the mouth and throat, vomiting, and esophageal damage.

Download the Skeletal Injuries Supplement

- Fractures are usually inflicted in nonambulatory children; 90% of all abusive fractures in children 2 years or younger include the ribs.
- Metaphyseal fractures: a chip of the metaphysis is pulled off by a ligament; can only occur from a jerking force applied to the extremities (for example, by shaking or swinging a child by the arms or legs).
- Spiral fracture: diagonal fracture usually caused by the twisting of an extremity; common in children due to more pliant bones - can occur very easily in small children by twisting their own leg or ankle in an accidental injury. Thus, spiral fractures are not necessarily indicative of abuse.
- Pelvic fractures: double vertical fractures through superior and inferior pubic rami and sacroiliac joint dislocation on the contralateral side; do not normally result from accidental injuries.
- Periosteal elevation: injury to this highly vascular tissue occurs when an infant’s extremities are twisted or shaken, causing the periosteum to be separated from the bone and blood to collect in the new space; if symmetric, it may be a normal variant.
- Rib fractures: can be caused by a caretaker squeezing the baby forcefully; victims may present with signs of respiratory distress, though are usually asymptomatic.

- Injuries to internal organs are caused by blows to the abdomen or squeezing; significant violent force is required to cause a life-threatening abdominal injury.
- Only a small percentage of children receive internal injuries from abuse; for those who do, the mortality rate is 40-50%.
- Signs and symptoms include: abdominal, chest, flank, or back pain; visible bruising of the chest or abdomen; distended, swollen abdomen; tense abdominal muscles; labored breathing or dyspnea; pleuritic pain; nausea or vomiting. However, many children exhibit minimal symptoms after abdominal trauma.

- Serious life-threatening cranial injuries, with the exception of epidural hematomas, do not result from a child falling from a short height such as a bed or crib.
- Skull fractures: more likely in young children - any pressure from cerebritis or or hemorrhage can separate fontanelles; brain injury is more likely due to increased subdural space in young children.
- Subdural hematoma: ruptured vessels in subdural space.
- Subgaleal hematoma: the scalp separates from the skull; often a sign of skull fracture and reason to image the skull; may be caused by jerking or twisting a child’s hair - especially in girls with pigtails - and may be evident by a bald spot. (Alopecia may be caused by neglect if the child lies on his or her back for long periods of time.)

- A child has been held around the upper thorax, under the arms, and shaken back and forth with great force or held upside down by the feet and shaken up and down.
- Many infants die, especially if there is a delay in getting treatment; those who survive often have permanent brain damage and may be paralyzed, developmentally delayed, or develop cerebral palsy.
- There is often an absence of externally visible injuries, but retinal hemorrhage is pathognomonic; subdural hematoma and metaphyseal lesions are common.

- Asphyxiation, suffocation, and drowning may be due to abuse.
- Blinding and eye injuries: blows to the eyes can result in a dislocated lens and, later, to cataracts; blows to the front or back of the head can result in bilateral black eyes (“raccoon eyes”) and/or massive swelling of the eyelids. Subconjuctival hemorrhage is caused by direct trauma (i.e. a blow to the face), but can be caused by birthing trauma; unrelated to retinal hemorrhage.
- Injuries to teeth, jaws, mouth, and lips: a strong blow is required to completely dislodge a tooth from its socket; injuries to the maxilla are rarely seen in accidents. Forced feeding of infants may cause bruised lips or a torn frenulum, which is pathognomonic of abuse.
- Damage to ears and hearing: blows to the ears or pinching and twisting of the ears can result in bruised pinna.
- Hair pulling: may see irregular patches of missing hair with broken hair visible, but no completely bald areas; be sure to distinguish from alopecia.

- 17% mortality rate, but more are nonintentional.
- Salt poisoning: forcing a child to swallow salt (often as a punishment for bedwetting); causes hypernatremia, which can lead to dehydration, vomiting, and seizures.
- Water poisoning: forcing a child to ingest water (often as a punishment for involuntary urination); causes hyponatremia, which can lead to convulsions, confusion, lethargy, and coma.
- Laxatives: cause diarrhea, which can lead to severe dehydration, fever, and bloody stools.
- Sedatives: symptoms include lethargy and coma.
- Pepper: ingesting black pepper can damage the mucous membranes of the oropharynx and stomach and may clog the throat and lungs, which can lead to apnea.

Physical Abuse: Signs and Symptoms

Physical Abuse: Signs and Symptoms

The following was adapted from the U.S. Department of Justice guide, “Child Neglect and Munchausen Syndrome by Proxy.”(2)

Munchausen syndrome by proxy (MSBP) is a form of child abuse wherein a parent or caretaker (usually the mother) intentionally fabricates illness in her child and repeatedly presents the child for medical care, disclaiming knowledge as to the cause of the problem. Child victims of MSBP are at risk for serious injury.

Diagnostic Criteria: MSBP occurs when there is:

• Illness in a child that is simulated (faked) or produced by a parent or other caretaker, or both.
• Presentation of the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures.
• Denial of knowledge by the parent or caretaker as to the cause of the child’s illness.
• Subsiding of acute symptoms and signs when the child is separated from the parent or caretaker.

Typically, but not always, the mother spends a good deal of time on the hospital ward with the child and exhibits a remarkable familiarity with medical terminology. She may be “confidentially friendly” with the hospital staff and other patients, although she may show frustration with her child’s chronic illness and anger at the medical staff’s inadequate vigor in pursuing her child’s problems. She may insist that she is the “only one” from whom the child will eat, drink, or swallow medications.

If more than one child in a family dies of SIDS or of any other ill-defined disease, MSBP - that is, homicide - along with some genetic, metabolic, environmental, and toxicological causes of death, must be considered as more likely explanations.

Common Presentation of Munchausen Syndrome by Proxy and the Usual Methods of Deception:

Physical Abuse: Signs and Symptoms

- Belittling, degrading, and other nonphysical forms of overtly hostile or rejecting treatment. - Shaming and/or ridiculing the child for showing normal emotions such as affection, grief, or sorrow. - Consistently singling out one child to criticize and punish, to perform most of the household chores, or to receive fewer rewards. - Public humiliation.

- Placing a child in unpredictable or chaotic circumstances. - Placing a child in recognizably dangerous situations. - Setting rigid or unrealistic expectations with threat of loss, harm, or danger if they are not met. - Threatening or perpetrating violence against the child. - Threatening or perpetrating violence against a child’s loved one or objects.

- Modeling, permitting, or encouraging antisocial behavior (i.e. prostitution, performance in pornographic media, initiation of criminal activities, substance abuse, violence to or corruption of others). - Modeling permitting, or encouraging developmentally inappropriate behavior (i.e. parentification, infantalization, living the parent’s unfulfilled dreams). - Encouraging or coercing abandonment of developmentally appropriate autonomy through extreme over-involvement, intrusiveness, and/or dominance (i.e. allowing little or no opportunity/support for the child’s views, feelings, and wishes; micromanaging the child’s life). - Restricting or interfering with cognitive development.

- Confining the child. - Placing unreasonable limitations or restrictions on social interactions with peers or adults in the community.

- Being detached and uninvolved through either incapacity or lack of motivation. - Interacting only when absolutely necessary. - Failing to express affection, caring, and love for the child.

Neglect: Signs and Symptoms