|Healthcare Training Institute - Quality Education since 1979CE for Psychologist, Social Worker, Counselor, & MFT!!
Manual of Articles Sections 7 - 13
V61.21 Physical Abuse of Child
Recognizing When a Child's Injury
or Illness is Caused by Abuse
Investigators must determine whether the explanation for an injury is believable.
Police should begin their investigation by asking the caretaker for an explanation
of the childs bruises or injuries. This is best done by asking the question:
How did the accident happen?
All bruises must be investigated. If bruises are
found on two or more planes of a childs body, investigators should be even
more suspicious. For example, a child has bruises on his buttocks and stomach.
The caretakers explanation is that the child fell backward in the living
room of the family home. This might explain the bruises on the buttocks, but not
the stomach bruises. If a discrepancy exists between the reported cause of an
injury and the injuries seen, law enforcement personnel should investigate further.
They should also keep in mind the following points:
- All other children in
the home should be examined for possible signs of child abuse.
- Victims of
physical abuse often have been intimidated and will usually support the abusers
version of how their injuries
occurred to avoid further injury. They also feel
that the abuse was just punishment because they were bad.
- A physical examination
of the child in suspected cases of maltreatment must be done and the data recorded
- Laboratory data should be obtained to support or refute the evidence
- If the reported history of an injury or injuries changes during
the course of an investigation, or if there is conflict between two adult caretakers
as to the cause of injury, the likelihood of child maltreatment increases.
The demeanor of the childs parents or caretakers is sometimes revealing.
For example, the mothers assessment of her pregnancy, labor, and delivery
will often provide an insight into her attitude about her child as well as give
an indication of whether there is something about the child that is influencing
- Investigators should ask questions in an unobtrusive manner;
Was this a planned pregnancy?
Did you want the
Do you like the baby?
How did the accident happen?
What were you doing just before the accident?
Who was at home at the
time of the accident?
What do you feed the baby? How often? Who feeds
- Information about a childs birth and his or her neonatal
and medical history are critical elements in investigations. Hospital records
can confirm or eliminate the existence of birth injuries.
- Any child may be
abused, and child abuse occurs in all levels of society. However, there are some
factors that increase a childs risk of abuse. These include:
birth or low birth weight.
Being identified as unusual or
perceived as different in terms of physical appearance or temperament.
Having a variety of diseases or congenital abnormalities.
emotionally, or developmentally disabled (e.g., mentally retarded or learning
Having a high level of motor activity, being fussy or irritable,
or exhibiting behavior that is different from the parents expectations.
Living in poverty or with families who are unemployed.
Living in environments
with substance abuse, high crime, and familial or community violence.
following are provided to help law enforcement personnel determine which injuries
and illnesses in children are likely to be the result of abuse. However, it is
also very important for law enforcement to work closely with physicians to determine
the nature of all injuries.
bruises, wounds, abrasions, or other skin lesions in varying states of healing
may indicate repetitive physical assault. Such repetitive accidents or injuries
may indicate that abuse is occurring. A careful examination of the circumstances
and types of injuries and an assessment of the child and family should be carried
out by a professional skilled in family dynamics, usually the social worker investigating
a report of suspected abuse. However, a police officer from the juvenile division
may in some circumstances be responsible for this, rather than a social worker.
The most common manifestations of non-accidentally inflicted
injuries are skin injuries. Several characteristics help to distinguish non-accidental
skin injuries from accidental ones, including their location and pattern, the
presence of multiple lesions of different ages, and the failure of new lesions
to appear after hospitalization. Law enforcement personnel should be sure to obtain
a complete history of all injuries from the caretaker.
are due to the leakage of blood into the skin tissue that is produced by tissue
damage from a direct blow or a crushing injury. Bruising is the earliest and most
visible sign of child abuse. Early identification of bruises resulting from child
abuse can allow for intervention and prevent further abuse.
Bruises seen in
infants, especially on the face and buttocks, are more suspicious and should be
considered non-accidental until proven otherwise. Injuries to childrens
upper arms (caused by efforts to defend themselves), the trunk, the front of their
thighs, the sides of their faces, their ears and neck, genitalia, stomach, and
buttocks are also more likely to be associated with nonaccidental injuries. Injuries
to their shins, hips, lower arms, forehead, hands, or the bony prominences (the
spine, knees, nose, chin, or elbows) are more likely to signify accidental injury.
Dating of Bruises
It is important to determine the ages of bruises to see
if their ages are consistent with the caretakers explanation of the times
of injury. Age dating of bruises can often be determined by looking at the color
of the bruise. The ages and colors of bruises may therefore show if more than
one injury is present. Table 1 shows the ages associated with the colors of bruises.
Determining the Age of a Bruise by Its Color
Red (swollen, tender):
Blue, purple: 2-5 days
Green: 5-7 days
Yellow: 7-10 days
No further evidence of bruising: 2-4 weeks
example, a 2-year-old boy, not toilet trained, has several yellow-to-brown bruises
on his buttocks. The caretakers explanation for the bruises is that the
child tripped in the hallway the day before and fell on his buttocks. This would
be suspicious because:
- Children seldom bruise their buttocks in accidental
- Bruises on the buttocks are in the primary target zone for non-accidental
- The childs diaper (whether disposable or cloth), plastic pants,
and clothing would have afforded some protection to his buttocks.
- If the
injuries causing the bruises were sustained the previous day, the bruises should
be red to purple.
Another child might have both bright red and brown bruises.
The caretaker maintains that all of the bruises were the result of a fall that
day. However, the bright red color indicates fresh bruises, while the brown bruises
are older. The caretakers explanation is, therefore, suspicious, and separate
explanations must be obtained for each bruise.
will sometimes have a specific configuration. This may enable law enforcement
officers to determine whether bruises are accidental or non-accidental. One of
the easiest ways to identify the weapon used to inflict bruises is to ask the
caretaker: How were you punished as a child? The pattern of a skin lesion may
suggest the type of instrument used. Bruise or wound configurations from objects
can be divided into two main categories: those from fixed objects,
which can only strike one of the bodys planes at a time, and those from
wraparound objects, which follow the contours of the body and strike
more than one of the bodys planes. Hands can make either kind of bruise,
depending on the size of the offenders hands and the size of the child.
Examples of fixed and wraparound objects include:
- Fixed objects: coat hangers,
- Wraparound objects: belts, closed-end (looped) cords, open-end
cords. (Closed-end cords leave a bruise in parallel lines; open-end cords leave
a bruise in a single line.)
Natural or Normal Bruising
by human hands, feet, or teeth or those inflicted by belts, ropes, electrical
cords, knives, switches, gags, or other objects will often leave telltale marks
(e.g., gags may leave down-turned lesions at the corners of the mouth). These
marks may also help in the investigative process. For example, the size of bite
marks may help to determine the biters approximate age; their shape may
help identify whose teeth made the marks. In some cases, however, bruises are
acquired innocently, through play and accidental falls, or when a child has a
defect in his or her clotting mechanism.
For example, a baby is brought to
the hospital with purple bruises on several body surfaces. The parents were unable
to provide an explanation other than that the baby bruised easily.
Blood tests later revealed that the baby was a hemophiliac; hemophilia is associated
with bruising easily, due to blood clotting problems. There is usually a history
of bruising easily in families with such inherited diseases. Other incidents of
easy bruising in children can be explainedby a low blood platelet
count. Multiple bruises can occur in children with leukemia. Diseases causing
easy bruising, however, are rare, and inflicted bruises are much more common.
The medical diagnosis of clotting disorders requires blood tests and interpretation
of those tests by qualified physicians. Therefore, law enforcement officers should
try to determine if bruises are the result of an accident or due to physical abuse.
must also remember never to jump to conclusions and to make a complete investigation
of all aspects of suspected child abuse. However, their first duty is to secure
the safety of the child quickly.
Mongolian spots (a kind of birthmark) also
resemble bruises but can be distinguished by their clear-cut margins, the fact
that they do not fade, and their steel gray-blue color. Mongolian spots may be
found anywhere on the body (but are typically found on the buttocks and lower
back). In addition, they are commonly found in African Americans, Asians, and
Hispanics. Investigators should await medical reports when investigating such
As shown in table 2, certain characteristics
of the history, location, or pattern of burns may indicate whether they were
That Burns May Not Have Been Accidental
- The burns are attributed
- An unrelated adult brings the child in for medical care.
Accounts of the injury differ.
- Treatment is delayed for more than 24 hours.
There is evidence of prior accidents or an absence of parental concern.
The lesions are incompatible with the history.
- The burns are
more likely to be found on the buttocks, in the anogenital region (the area between
the legs, encompassing the genitals and anus), and on the ankles, wrists, palms,
- The burns have sharply defined edges. For example,
in immersion burns, the line of immersion gives the appearance of a glove or stocking
on the childs hand or foot.
- The burns are full thickness (all of the
skin, and possibly muscle and bone as well, is destroyed).
- The burns are
- The burns are older than the reported history indicates.
The burns have been neglected or are infected.
- There are numerous lesions
of various ages.
- The burn patterns conform to the shape of the implement
- The degree of the burns is uniform (usually indicating forced
with a hot, dry object), and they cover a large area.
That Burns Are More Likely To Be Accidental
- The burns are
usually found on the front of the body. They occur in locations reflecting the
childs motor activity, level of development, and the exposure of the childs
body to the burning agent.
- The burns are of multiple depths interspersed
with unburned areas and are usually less severe (such as splash burns).
burns are of partial thickness; that is, only part of the skin has been damaged
- The burns are asymmetrical.
- Apparently only one traumatic
event has occurred, because the skin injuries are all of the same age.
Bays exhaustive review of the worlds literature of reported cases
of non-accidental poisoning as a form of child abuse identified certain agents
that are commonly used by perpetrators (Conditions Mistaken for Child Sexual
Abuse, in Reece, R.M. (ed.): Child Abuse: Medical Diagnosis and Management).
The most frequently used agents included barbiturates, psychoactive drugs, tranquilizers,
insulin, ipecac, arsenic, laxatives, salt, water, alcohol, marijuana, and opiates.
The children poisoned by such agents display a variety of presenting signs and
symptoms, but nearly all have major changes in their mental status, ranging from
irritability, listlessness, lethargy, stupor, and coma to convulsions. The peak
age for accidental poisoning is 2 to 3 years, and it is rare under the age of
1 or over the age of 6. The usual history of non-accidental poisoning is that
either the ingestion was not witnessed or that it was administered by a sibling
or another child. In addition, the history may change over time.
Many fatalities from child abuse involve serious head injuries.
Subdural hematomas due to child abuse are most common in children less than 24
months of age, with the peak incidence at about 6 months. The signs and symptoms
of subdural hematomas may either be nonspecific, including irritability, lethargy,
or a disinclination to eat, or there may be more classic signs of raised intracranial
pressure such as vomiting, seizures, stupor, or coma. A subdural hematoma associated
with a skull fracture is due to a direct impact to the head and ordinarily leaves
external marks. It may be associated with shaking the baby violently or with an
extreme blow to the head, such as occurs when children are thrown against a hard
object. Retinal hemorrhages strongly suggest whiplash or shaking as the origin
of the injury. The presence of bilateral subdural hematomas is also positively
correlated with whiplash or shaking. Therefore, law enforcement personnel need
to investigate whether these were non-accidental injuries. Hair pulling as a means
of discipline may be responsible for hair loss or baldness (alopecia).
- External eye injuries are so common in children that they are
seldom clear-cut evidence of abuse.
- Two black eyes seldom occur together
- The raccoon eyes associated with accidental and
non-accidental fractures at the base of the skull may look similar to each other,
but raccoon eyes from non-accidental trauma usually are associated with more swelling
and skin injury. The history helps distinguish between them.
- Hyphema, the
traumatic entry of blood into the front chamber of the eye, may be the result
of a nonaccidental injury caused by striking the eye with a hard object, such
as a belt buckle. The child will complain of pain in the eye and have visual problems.
Retinal hemorrhages are the hallmark of shaken baby syndrome and are only rarely
associated with some other mechanism of injury.
- Non-accidental trauma must
always be considered in a child under 3 years of age who has retinal hemorrhages
or any traumatic disruption of the structures of the globe of the eye (e.g., the
lens or retina) or the skin around the eye.
Checklist for Use in Suspected Cases of Physical Child Abuse
Far too often
police investigating a childs injuries will let their emotions interfere.
It should be remembered that the child abuse investigation process, if performed
correctly, will ultimately determine which injuries were non-accidental. The following
are some important questions and issues to be considered when investigating a
suspected case of child abuse.
- Begin by asking questions about the childs
family history, substance abuse or other environmental factors in the home, and
the parents marital status, employment history, or unrealistic expectations
of the child.
- How could the childs behavior or the caretakers
stress have contributed to the crisis?
- Could the child do what the caretakers
told you he or she did?
- Is the child a target child (a child
perceived by the parent(s) as having negative characteristics), or are there target
- Was there any delay in treatment or was hospital shopping
- What are the locations, configurations, and distributions of the
bruises, welts, lacerations, abrasions, or burns?
- Do the injuries appear
to have been caused by the hands or an instrument? Can you determine what instrument
might have been used?
- Are multiple injuries (in various stages of healing)
- Are the injuries within the primary target zone (the back, from
the neck to the back of the knees and including the
shoulders and arms) and
on more than one leading edge (the outside of the arm or leg, etc.) of the body?
Can you determine the positions of the offender and the child during the attack?
Is there any evidence of attempts to hold the child in a certain position or at
a certain angle during the attack? Are there such control marks on the wrists,
forearms, or biceps?
- Was a careful check made for injuries on the head, mouth,
ears, and nose?
- Farley M.S., Robert Hugh, and Robert M. Reece
M.D., Recognizing When a Childs Injury or Illness is Caused by Abuse,
U.S. Department of Justice, 2002, http://www.ncjrs.gov/pdffiles1/ojjdp/160938.pdf
The article above contains foundational information. Articles below contain optional updates.
is no question for the Introduction
The next question is found in the next
section, Section 8