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Physical Abuse
Physical Indicators
Physical abuse is often the most obvious form of abuse. It
is any non-accidental injury to a child by a parent or caretaker.
The mandated professional should pay close attention to any
frequent injuries that are "accidental" or "unexplained",
or that are developmentally unlikely or any explanation that
seems unlikely.
Physical abuse may present as (NYS-OCFS, 2011; CDC, 2015):
- Frequent and unexplained bruises
- On face, lips or mouth;
- On torso, back, buttocks, thighs;
- May be in various stages of healing;
- On several different surface areas of the body;
- May appear in distinctive patterns reflecting the
shape of the article used such as grab marks or human
bite marks, electric cord, belt buckle, etc.;
- Fading bruises or other marks noticeable after an
absence, weekend or vacation from school or day care.
- Burns
- Cigar or cigarette burns, especially on the soles,
palms, back and buttocks;
- Immersion burns (sock-like, glove-like, or doughnut
shaped on buttocks or genitalia from having feet, hand
buttock/genitals immersed in scalding water);
- Distinctive patterned burn impressions from appliances
or instruments such as steam irons, curling irons, etc.;
- Rope burns on arms, legs, neck or torso.
Steam Iron Injury
Photo courtesy of NYS-OCFS
Handprint Injury
Photo courtesy of NYS-OCFS
Looped Cord Injury
Photo courtesy of NYS-OCFS
- Cuts;
- Welts;
- Swelling;
- Sprains;
- Fractures
- To skull, nose, facial structures;
- In various stages of healing;
- Multiple or spiral fractures
- Swollen or tender limbs.
- Lacerations or abrasions
- To mouth, lips, gums, eyes;
- To external genitalia;
- On backs of arms, legs or torso;
- Human bite marks.
- Injuries to the eyes or both sides of the head or body
(accidental injuries typically only affect one side of the
body;
Child's Behavior - Possible Indicators of Physical
Abuse
The following behavioral signs do not necessarily mean that
a child is abused or maltreated, but should be considered
in light of other indicators. These behavioral indicators
are often general, potentially pointing to a problem that
may or may not relate to abuse/maltreatment.
- Wary of adult contacts; may shrink at the approach of
adults;
- Apprehensive when other children cry;
- May be overly afraid of the parent's reaction to misbehavior;
- Shows sudden changes in behavior or school performance;
- Has not received help for physical or medical problems
brought to the parents' attention;
- Has learning problems (or difficulty concentrating) that
cannot be attributed to specific physical or psychological
causes;
- Is always watchful, vigilant, as though preparing for
something bad to happen;
- Lacks adult supervision;
- Is overly compliant, passive, withdrawn or emotionless
behavior;
- Destructive, aggressive or disruptive behavior;
- Behavior extremes, such as appearing overly compliant
and passive or very demanding and aggressive or withdrawn;
- Comes to school or other activities early, stays late,
and does not want to go home;
- Uncomfortable with physical contact;
- Low self esteem;
- Lags in physical, emotional, or intellectual development;
- Seems frightened of the parents and protests or cries
when it is time to go home;
- Is either inappropriately adult (parenting other children,
for example) or inappropriately infantile (frequently rocking
or head-banging, for example);
- Has attempted suicide;
- Reports a lack of attachment to the parent;
- Reports injury by parent;
- Wears long sleeved or similar clothing to hide injuries;
- Seeks affection from any adult.
Parent's Behavior - Possible Indicators of Physical
Abuse
- Shows little concern for the child;
- Denies the existence of-or blames the child for-the child's
problems in school or at home;
- Takes an unusual amount of time to obtain medical care
for the child;
- Attempts to conceal the child's injury;
- Takes the child to a different healthcare provider or
hospital for each injury;
- Offers an inadequate or inappropriate explanation for
the child's injury;
- Offers conflicting, unconvincing, or no explanation for
the child's injury;
- Disciplines the child too harshly considering the child's
age or what s/he has done wrong
- Asks teachers or other caretakers to use harsh physical
discipline if the child misbehaves;
- Sees the child as entirely bad, worthless, or burdensome;
- Demands a level of physical or academic performance the
child cannot achieve;
- Looks primarily to the child for care, attention, and
satisfaction of emotional needs;
- Describes the child as "evil," or in some other very
negative way;
- Has a history of abuse as a child;
- Is unduly protective of the child or severely limits
the child's contact with other children especially of the
opposite sex;
- Is secretive and isolated;
- Is jealous or controlling with family members;
- Constantly blames, belittles, or berates the child;
- Is unconcerned about the child and refuses to consider
offers of help for the child's problems;
- Overtly rejects the child;
- Appears to be indifferent to the child;
- Seems apathetic or depressed;
- Behaves irrationally or in a bizarre manner;
- Has poor impulse control;
- Is abusing alcohol or other drugs.
Pediatric Abusive Head Trauma
Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT) is a term used to describe the constellation of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child (NCSBS, nd). The American Academy of Pediatrics (AAP) describes SBS as a subset of AHT with injuries having the potential to result in death or permanent neurologic disability. They further clarify that “The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required…The American Academy of Pediatrics supports prevention efforts that reduce the frequency of AHT and recognizes the utility of maintaining the use of the term “shaken baby syndrome” for prevention efforts.” (NCSBS, nd).
Shaken infant syndrome has been the most widely used and recognized term, although shaking alone may not account for all injuries. In 2009, the American Academy of Pediatrics, in a policy statement (Christian, et al., 2009), stated,
“ Shaken baby syndrome is a term often used by physicians and the public to describe abusive head trauma inflicted on infants and young children. Although the term is well known and has been used for a number of decades, advances in the understanding of the mechanisms and clinical spectrum of injury associated with abusive head trauma compel us to modify our terminology to keep pace with our understanding of pathologic mechanisms. Although shaking an infant has the potential to cause neurologic injury, blunt impact or a combination of shaking and blunt impact cause injury as well. Spinal cord injury and secondary hypoxic ischemic injury can contribute to poor outcomes of victims. The use of broad medical terminology that is inclusive of all mechanisms of injury, including shaking, is required. The American Academy of Pediatrics recommends that pediatricians develop skills in the recognition of signs and symptoms of abusive head injury, including those caused by both shaking and blunt impact, consult with pediatric subspecialists when necessary, and embrace a less mechanistic term, abusive head trauma (AHT), when describing an inflicted injury to the head and its contents.”
According to the CDC (2012a), pediatric abusive head trauma is defined as an injury to the skull or intracranial contents of an infant or young child (< 5 years of age) due to inflicted blunt impact and/or violent shaking.
According to the National Center on Shaken Baby Syndrome (NCSBS, nd), approximately 1,300 U.S. children experience severe or fatal head trauma from child abuse every year. Abusive head injuries are the most common cause of death in child abuse (Case & NCSBS, nd). Estimates of the incidence of abusive head trauma vary, but most range from 20 to 30 cases per 100,000 children under 1 year of age (CDC, 2015a).
Approximately 20% of cases of abusive head trauma are fatal in the first few days after injury and the majority of the survivors are left with handicaps ranging from mild - learning disorders, behavioral changes - to moderate and severe, such as profound mental and developmental retardation, paralysis, blindness, inability to eat or existence in a permanent vegetative state (NCSBS, nd). Dias, et al. (2005) reported that 13 to 30% of pediatric abusive head trauma cases result in mortality and significant neurologic impairments occur in at least one half of the survivors. The NCSBS (nd) reported that more than 80% of victims of shaken baby syndrome have lifetime impairments and 25% die from their injuries.
Medical costs associated with initial and long-term care for children who are victims of AHT can range from $300,000 to more than $1,000,000 (NCSBS, nd). Additional costs associated with loss of societal productivity and occupational revenue and with prosecution and incarceration of a perpetrator are unknown (Dias, et al., 2005). The total societal economic impact is estimated to be 16.8 billion dollars (NCSBS, nd).
Parents and their partners are responsible for nearly three fourths of cases, with fathers or stepfathers (37% of cases) and boyfriends (21% of cases) accounting for the majority of cases and mothers accounting for an additional 13%. The average age of the victims is 5 to 9 months, and almost all are less than 36 months of age (Dias, et al., 2005; CDC, nd).
The incidence rate decreases with increasing age; those 1 year of age or younger have a substantially higher incidence. The peak incidence and rapid decrease with age are thought to be related to episodes of prolonged, inconsolable, and unpredictable crying that are developmentally normal for infants (CDC, 2015a). Episodes of crying that can trigger shaking behavior among parents and caregivers are known to increase in the first month after birth, peak in the second month, and decrease thereafter. While the majority of victims are under 2 years of age and the peak incidence is typically found from 2-3 months, injuries consistent with abusive head trauma have been found in children as old as 5 years of age (CDC, 2015a).
Serious traumatic brain injury in young children is largely the result of abuse and results in significant morbidity and mortality. Among United States children, abuse is the third leading cause of all head injuries, after falls and motor vehicle crashes. For children in the first year of life, the majority of serious head injuries result from abuse. Estimates of the incidence of abusive head trauma vary, but most range from 20 to 30 cases per 100,000 children under 1 year of age.
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