The Study of Child Maltreatment

We study child abuse and neglect for a very simple reason. These children need our help, and the alternative to not acting could result in the death of a child. The long-term sequellae of years of maltreatment are somewhat more difficult to quantify. Children who are maltreated do not do well in school. These children have poor peer relationships, do not form adequate attachments later in life, and often develop antisocial and criminal behaviors. In addition, children who have been maltreated may often abuse their own children, perpetuating the cycle of maltreatment from generation to generation.

Risk Factors

There are several risk factors, which should serve as red flags and prompt the provider to screen more closely for the presence of child abuse or neglect. The single most common thread tying many of these cases together is the presence or threat of domestic violence. Children are often caught in the middle of violent domestic disputes or may become the passive victims of their parents’ actions. Additionally, later in life these children act out what they have learned, namely, that violence is the method for solving their marital problems. In addition, child abuse is very common in families where there is a history of drug or alcohol abuse. In many of these chaotic homes, the children’s needs are not a priority due to their parents’ addiction. Financial issues resulting from substance abuse not only cause strain in the family but also impact the child’s ability to thrive in a healthy environment. Unemployment can add to the financial difficulties but more important it can create a loss of parental self-esteem. Families where there is a history of mental illness must also be carefully screened for the potential for maltreatment. Due to the current economic crises in our country, we are rapidly creating a society of latchkey children who come from school and are forced to take care of themselves and younger siblings until their parents return home from work. In extreme cases, children have been left alone for days at a time, leading to reports of neglect to Child Protective Services.

With the increase of female head-of-house-hold families, we also see young boys forced into roles that traditionally have been the responsibilities of the absent father, again creating an increased risk. Children learn how to become parents based on the way they have been parented. If they have been abused, there is a good chance that, without adequate prevention programs, such as home visitation to teach and support young parents, the cycle of child abuse will continue, and the young parent may abuse his or her own children. With teenage pregnancy, children are having children, usually without the necessary family supports or role models for parenting; this can lead to child maltreatment. Additionally, the young teenager now in a new role of parent without support becomes isolated at a time when family support is most needed. Overwhelmed and unable to manage the young infant, the teen has the potential of harming or neglecting the infant.

Although these risk factors in and of themselves do not serve as indicators of child maltreatment, they need to be considered and carefully probed when they are elicited in a family’s history. These risk factors rarely exist in isolation, and, with a careful medical and psychosocial assessment, a more complete picture of child maltreatment, abuse, or neglect may be uncovered.

Indicators

Physical Indicators of Child Maltreatment, Abuse, and Neglect

Unexplained bruises, welts, and bite marks on areas of the body that are usually protected are considered significant and probably inflicted. These include the face, lips, neck, wrists, ankles, back, inner thighs, and torso. Injuries that are bilaterally symmetrical, such as to both eyes, or that are circumferential are usually inflicted. The classic history of the child with two black eyes that “walked into a doorknob” is just one example of a history that gives you reasonable cause to suspect abuse. The likelihood of this type of injury would not be consistent with the physical examination. When bruises are in various stages of healing, the provider’s level of suspicion should increase, leading to further assessment of the situation. These injuries include fresh purple or red marks as well as older healing green, yellow, or brown marks; this is called the “garden effect” because of all the colors. Clustered or repeated patterns of marks often in the shape of the article used to inflict the injury (belts or electric cord loop marks) are not uncommon in child physical abuse. Human bite marks need to be assessed carefully by a dentist to determine whether the bite marks were inflicted by an adult or a child. The dentist will usually measure the diameter of the lesion to reach a determination. Unexplained lacerations or abrasions are also indicative of abuse, especially when located on the lips, gums, eyes, or genitalia. Bald patches on the scalp should also be questioned and usually indicate that the child’s hair was pulled out.

Unexplained burns from cigars or cigarettes that appear on the palms, soles, or genitalia are usually inflicted and significant for child abuse. The provider must be aware that burns are a product of both time and temperature, and it is instinctive for the child to pull away from a burning object unless held there. Patterned burns such as from curling or steam irons or rope burns of the arms, legs, or neck must also be considered suspicious for abuse and must be carefully assessed. Immersion burns from scalding water—“the dunking baby syndrome”— are suspicious for inflicted injuries due to symmetry of the burns as well as the absence of splash marks usually found in accidental scalding injuries.

Unexplained fractures or dislocations or any injuries where there is a delay in seeking medical attention must also be considered as potentially neglectful. Skull, nose, or other facial bone fractures or any fracture in various stages of healing are worrisome and require further investigation. Spiral fractures in the absence of a plausible history or bucket handle fractures are considered to be indicative of abuse.

Physical neglect or failure to thrive is somewhat less striking and difficult to assess to reach a diagnosis of child abuse. Children often demonstrate poor growth or weight gain, failure to thrive, poor hygiene, abdominal distention, or wasting of subcutaneous tissues. Children who present to the office hungry or inappropriately dressed for the season and whose medical needs are not being met or who are left alone or abandoned should be admitted to the hospital for medical evaluation and treatment in conjunction with a social service assessment and a report to Child Protective Services.

Specific Ophthalmologic Concerns

Types of inflicted head injuries can include retinal hemorrhages and dislocated lenses, skull fractures, subdural hematomas, scalp bruises, and black eyes. Inflicted subdurals can be found with evidence of inflicted trauma such as fractures, scalp swelling, and bruises or without evidence of external trauma, as in the classic shaken baby syndrome or a whiplash injury, where there is no evidence of scalp swelling, skull fracture, or bruising. It is important to remember, however, that both types of subdurals can be associated with retinal hemorrhages and dislocated lenses. Subdural hematomas are rarely spontaneous in nature, and in the absence of a plausible history an inflicted injury must be considered.

Funduscopic examinations must be performed on all children under 2 years of age where there is a concern of inflicted injury or evidence of trauma, especially when head trauma is present. Retinal hemorrhages may be the only clue to the presence of subdural hematomas from a whiplash injury where there is no evidence of external trauma.