General Considerations #
Identification of child abuse may be difficult. It normally requires both social and medical assessment.
Always listen to the child – pay particular attention to any spontaneous statement.
Beware if explanation of an “accident” is vague, lacking detail, is inconsistent with the injury or varies with each telling.
Take note of inappropriate responses from parents or carers.
Observe the child’s interaction with the parents – particularly wariness, fear or “frozen watchfulness” i.e. persistent anxious regard of an adult by a baby or young child.
Any history or patterns of unexplained injury/illness requires the most careful scrutiny. (The fact that parent/carer appears to be highly attentive and concerned must not divert attention from the assessment of risk).
Physical Abuse #
Some signs that may be due to physical abuse are:
Bruises
- One or both eyes are bruised.
- Grasp marks on the limbs or finger tip bruises on the chest of a small child.
- Finger marks on the face (i.e. 3-4 small bruises on one side of the face and one on the other).
- Symmetrical bruising.
- Bruising to the ear.
- Outline bruising (i.e. belt marks, hand prints, shoe marks).
- Linear bruising (particularly on the buttocks or back).
- Bruising on soft tissue with no obvious and verifiable explanation.
- Different age bruising (especially in the same area).
- The following are uncommon sites for accidental bruising:
- Mouth, cheeks, behind the ear, neck, abdomen, chest, under the arm, back, back of legs, buttocks (except occasionally along the bony protuberances of the spine), genital area, rectal area, soles of feet.
Bites, Burns and Scars
- Oval or crescent shaped bites. Bites more than 3cm across will have been caused by an adult or older child.
- Burns or scalds with clear outlines.
- Burns of uniform depth over a larger area.
- (A responsible adult checks the temperature of the bath before a child gets in. A mobile child is unlikely to sit down voluntarily in too hot a bath, and cannot accidentally scald his/her bottom without also scalding their feet. Also, a child getting into too hot water of its own accord will struggle to get out again and there will be splash marks.)
Most children have scars. Notice must be taken of:
- An exceptionally large number of differing age scars (especially if coupled with current bruising), or unusual shaped scar.
- Small round burns which may be cigarette burns.
Other Injuries
- Pain, swelling and discoloration over a bone or joint (the most common non-accidental fractures are to the long bones i.e. arms, legs, ribs and collar bones).
- Allegedly unnoticed fractures – fractures cause pain and it is difficult for a parent to be unaware that a child has been hurt.
- Poisoning, injections, ingestion or other application of damaging substances (including drugs or alcohol) which are inappropriate to the child’s needs and age.
- Illness which is fabricated e.g. symptoms induced by suffocation.
- Female genital mutilation, which includes female circumcision, excision and infibulation, is physical abuse and an offence regardless of cultural or other reasons (except medical grounds).
Emotional Abuse #
Children suffering emotional abuse may show:
- Abnormally passive, lethargic or attention seeking behaviour.
- Specific habit disorders e.g. soiling with faecal smearing, excessive drinking, self-mutilation, inappropriate appetite, i.e. persistent eating of inedible substances.
- Severely delayed social development; poor language and speech development attributable to actions/inactions of parent/carer.
- Weight and height which is disproportionately low that cannot be explained by medical reason.
Sexual Abuse #
Some signs that may be due to sexual abuse are:
- Sexually transmitted diseases.
- Genital warts.
- Recurrent urinary infections.
- Genital and rectal itching and soreness.
- Unexplained bleeding and discharges.
- Bruising in genital region.
- Inappropriate sexual play and/or masturbation.
- Sexually explicit behaviour.
- Young children with a lot of sexual knowledge.
- Accompanying conditions (which also occur in non-abused children):
- Sleeping and eating disturbance.
- Recurrent abdominal pains.
- Headaches, sleeping and appetite disorders.
- Social withdrawal.
- Restlessness and aimlessness.
- Sexually abusive behaviour towards other children, particularly those younger and/or more vulnerable than themselves.
- Poor trust and secretiveness.
- Promiscuous behaviour.
- Drug abuse.
- Running away.
- Self-mutilation.
- Suicide attempts.
- Hysterical fits, faints, etc.
N.B. In many cases, a sexually abused child presents no physical symptoms of abuse. The most important indicator is what the child says her/himself.
Involvement of a child by an adult in unlawful sexual activities is sexual abuse, whether this is apparently forced or apparently willing; and whether this is an abuse of position, paid or rewarded by persons known by or strangers.
