Overview
This lecture covers child abuse recognition and the clinician’s role in child protection, opening with a case of an infant with occult rib fractures. It works through why abuse is under-recognised, prevention by targeting risk factors, the concept of sentinel injuries and findings that should raise suspicion (including bruise patterns), the process of making a report, and the clinical protocol for evaluating a child with suspected maltreatment (history, exam, documentation, investigations).
Why abuse is under-recognised, and why it matters
- Most people struggle with the idea that caretakers could injure children.
- Caretakers rarely disclose maltreatment.
- Pre-verbal or obtunded children cannot give a history.
- Physical exam findings may be subtle or non-specific.
- Despite this, child abuse is common, and the lecture emphasises this repeatedly.
- The clinician’s role (“our job and privilege”) is protection, advocacy, promoting wellness, and decreasing/eliminating exposure to trauma and violence.
Prevention by targeting risk factors
Risk factors are grouped into three categories:
- Parental: intimate partner violence (IPV), single or teen parent, a non-related adult living in the home, missed perinatal care.
- Child: prematurity, low birth weight, in-utero drug exposure, developmental/physical disabilities, age.
- Social: isolation, poverty, low education, large family size.
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Two key factors singled out for targeted prevention:
- IPV: screening for and discussing IPV with families can reduce children’s exposure to violence.
- Developmental problems: caretakers with inaccurate expectations of a child’s developmental abilities (e.g. how long infants cry, when toddlers can be toilet trained) are at higher risk of maltreatment; addressing these expectations specifically targets infant crying and toddler toilet-training capacity.
Sentinel injuries and findings
Sentinel injuries are unexplained or insufficiently explained injuries noted by medical professionals before a subsequent presentation for abusive injury; multiple studies show they often precede confirmed abuse. Whether an injury requires a child protection exam depends on the child’s age/development, the injury itself, the adequacy of the history, and physical exam findings.
Sentinel concerns – Age/Development
- Any injury in a non-mobile child
- Injury in a non-verbal child
- Injury inconsistent with developmental stage
- A statement of harm from a verbal child
Sentinel concerns – Injury
- Any injury in a non-mobile child
- Occult findings
- Implausible mechanism of injury
- Multiple injuries or injuries of multiple ages
- Patterned cutaneous lesions
- Burns to the groin, in a stocking distribution, branding marks, or patterned burns
- “TEN-4” bruising in children under 4 years old
Sentinel findings – History
- Inadequate concern shown for the injury
- Implausible or inconsistent history
- Caretaker response or timing of response not commensurate with the injury
- Inconsistencies between different caretakers’ accounts
Key message: injuries are common in childhood, and yet almost any injury could be abusive — the context and pattern matter, not the injury type alone.
Bruises
- Bruise age cannot be reliably estimated (“you can’t date a bruise”).
- Problematic bruise locations in children under 4 years old: torso, ear, neck (the “TEN-4” mnemonic: Torso, Ear, Neck, age <4 years).
- Any bruising at all in an infant under 4 months old is concerning.
Making a report
- Health care workers are mandated (via their work contract) to report suspected child maltreatment to Oranga Tamariki and/or police when there is reasonable cause to suspect it.
- Final determination of abuse is made by the multidisciplinary team, but that process does not begin until a report is made.
- Clinicians must balance concern for the child against the distress a notification will cause the family.
- Approach to families: advocate for the child (a role families can often support), and emphasise that the report follows a fixed protocol, which removes it from a power struggle (“we follow this protocol to ensure the health of our children”).
- A Report of Concern is made via MIDAS search; a copy of the Report of Concern is forwarded to the relevant Violence Intervention Programme Child Protection Service.
- Where possible, clinicians are encouraged to speak with whānau about their concerns and inform them of the plan to contact Child, Youth and Family before referral — unless the child or clinician is at immediate risk of harm, in which case referral can be made without prior contact.
- If a Child, Youth and Family social worker is consulted about the referral, the clinician should record: name of the social worker, date/time of the conversation, and outcome of the discussion.
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Calling for back-up and forensics
- Paediatrics: arrange admission, advice, formal assessment.
- Social work: intervene with the family, assess safety.
- Police: protection, law enforcement, and managing against-medical-advice (AMA) exits.
- Forensics note: if forensic information is to be gathered (especially for suspected sexual assault), take care to preserve potential evidence such as clothes, hair, wounds, and fingernails.
The clinical protocol
The protocol for evaluating suspected child maltreatment: History, Physical exam, Genital exam (specialised), Photo-documentation, Evaluations, Report and safety plans.
History – HPI
- Interview caregivers separately.
- Note the caregiver’s ability to provide a history.
- Review developmental history.
- Create a timeline of when the patient was last in usual health and how the patient appeared between caregivers.
- Note witnesses, photos, etc.
History – other
- Past medical history: history of skeletal trauma, cutaneous injuries, past traumatic brain injury.
- Social history: list all adults with access to the child and all children in the home; history of substance abuse, domestic violence, mental illness, and previous CYFS (Child, Youth and Family Service) cases.
- Family history: bone diseases, bleeding disorders.
Physical exam
- Growth parameters/trajectories and head circumference.
- Head-to-toe exam including intra-oral, genitals, ears, and bottom of feet.
Photo-documentation
- If photos are taken, document the details: location of injuries, number of photos, date, and photographer.
- If photos are unavailable, use a body diagram detailing lesions by size, location, and colour.
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Evaluations
- Laboratory tests: full blood count, coagulation studies, electrolytes.
- Imaging: skeletal survey, head CT, MRI.
- Subspecialist communication: orthopaedics, haematology, ophthalmology, metabolic, neurosurgery.
Closing points
- Consider child maltreatment in any young child with unexplained injuries, or when discrepancies exist between exam findings, history, and developmental ability.
- Child abuse is a major source of both childhood and adult morbidity and mortality.
- All medical professionals have a responsibility to identify children with concerns for maltreatment, provide a thoughtful exam, communicate with families, and report cases to social welfare agencies.
Self-test
- List the three categories of risk factors for child maltreatment (prevention framework), with one example from each.
- What are the two key factors specifically targeted for prevention, and how does each reduce risk?
- Describe the sentinel concerns related to a child’s age and development that should raise suspicion of abuse.
- List the sentinel concerns related to the injury itself.
- What features of a caretaker’s history should raise suspicion of abuse?
- What does the “TEN-4” mnemonic stand for, and why is it significant?
- Why can bruise age not reliably be estimated, and what is the clinical implication of this?
- Describe the legal and procedural obligation of a health care worker who has reasonable cause to suspect child maltreatment.
- A clinician wants to refer a family to Child, Youth and Family but is worried about damaging trust with the whānau. Describe the recommended approach, and the exception to it.
- Distinguish the roles of paediatrics, social work, and police when “calling for back-up” in a suspected abuse case.
- Why is preserving evidence emphasised in cases of suspected sexual assault, and give examples of evidence to preserve.
- List the six steps of the clinical protocol for evaluating suspected child maltreatment, in order.
- What specific elements should be covered in the past medical, social, and family history when abuse is suspected?
- Describe what should be documented if photographs of injuries cannot be taken.
- List the laboratory and imaging evaluations used when investigating suspected child abuse.
Answers
Reveal answers
- Parental (e.g. IPV, single or teen parent, non-related adult living in home, missed perinatal care); Child (e.g. prematurity, low birth weight, in-utero drug exposure, developmental/physical disabilities, age); Social (e.g. isolation, poverty, low education, large family size).
- IPV (screening for and discussing IPV with families reduces children’s exposure to violence) and developmental problems (correcting caretakers’ inaccurate expectations of developmental abilities, particularly around infant crying and toddler toilet training, reduces maltreatment risk).
- Any injury in a non-mobile child; injury in a non-verbal child; injury inconsistent with the child’s developmental stage; a statement of harm from a verbal child.
- Any injury in a non-mobile child; occult findings; implausible mechanism of injury; multiple injuries or injuries of multiple ages; patterned cutaneous lesions; burns to the groin, in a stocking distribution, branding, or patterned burns; TEN-4 bruising in children under 4 years.
- Inadequate concern shown for the injury; implausible or inconsistent history; a caretaker response or timing of response not commensurate with the injury; inconsistencies between different caretakers’ accounts.
- Torso, Ear, Neck bruising in children under 4 years old (plus any bruising at all under 4 months old); it is significant because these are the “problematic” bruise locations/ages most associated with abuse.
- Bruise age cannot be reliably estimated from its appearance (“you can’t date a bruise”), so clinicians cannot use bruise colour/appearance to confirm or refute a given timeline from a caretaker.
- Health care workers are mandated, via their work contract, to report to Oranga Tamariki and/or police whenever there is reasonable cause to suspect child maltreatment; the multidisciplinary team makes the final determination of abuse, but that process cannot begin until the report is made.
- Where possible, speak to the whānau about the concerns and let them know of the plan to contact Child, Youth and Family before referring, framing it as following a fixed protocol rather than a personal accusation, and advocate for the child. The exception is if the child (or the clinician) is at immediate risk of harm, in which case a referral can be made without prior contact with the whānau.
- Paediatrics arranges admission, advice, and formal assessment; social work intervenes with the family and assesses safety; police provide protection, law enforcement, and manage against-medical-advice exits.
- Forensic evidence can be lost or destroyed if not carefully preserved, which may compromise both child protection and legal processes; examples given are clothes, hair, wounds, and fingernails.
- History, Physical exam, Genital exam (specialised), Photo-documentation, Evaluations, Report and safety plans.
- Past medical history: history of skeletal trauma, cutaneous injuries, past traumatic brain injury. Social history: all adults with access to the child and all children in the home, history of substance abuse, domestic violence, mental illness, and previous CYFS cases. Family history: bone diseases and bleeding disorders.
- A body diagram detailing the lesions by size, location, and colour.
- Laboratory: full blood count, coagulation studies, electrolytes. Imaging: skeletal survey, head CT, MRI. Plus subspecialist communication with orthopaedics, haematology, ophthalmology, metabolic medicine, and neurosurgery.