APPENDIX 3 - Signs and Symptoms of Child Abuse

 

This section contains information for all professionals working with children and families and is not an exhaustive list. The following pages provide guidance only and should not be used as a checklist.

 

2.1        The first indication that a child is being abused may not necessarily be the presence of a severe injury. Concerns may become apparent in a number of ways e.g.

 

• by bruises or marks on a child's body

• by remarks made by a child, his parents or friends

• by overhearing conversation by the child, or his parents

• by observing that the child is either being made a scapegoat by or has a poor relationship/bond with his parents.

• by a child having sexual knowledge or exhibiting sexualised behaviour which is unusual given his age and/or level of understanding.

• by a child not thriving or developing at a rate which one would expect for his age and stage of development.

• by the observation of a child's behaviour and changes in his behaviour.

• by indications that the family is under stress and needs support in caring for their children.

• by repeat visits to a general practitioner or hospital.

 

2.2        There may be a series of events which in themselves do not necessarily cause concern but are significant, if viewed together. Initially the incident may not seem serious but it should be remembered that prompt help to a family under stress may prevent minor abuse escalating into something more serious.

 

2.3        It is important to remember that abused children do not necessarily show fear or anxiety and may appear to have established a sound relationship with their abuser(s). Staff should familiarise themselves on 'attachment theory' and its implications for assessing the bond between parents and their children.

 

2.4        Suspicions should be raised by e.g.

 

• discrepancy between an injury and the explanation

• conflicting explanation, or no explanation, for an injury

• delay in seeking treatment for any health problem

• injuries of different ages

• history of previous concerns or injuries

• faltering growth (failure to thrive)

• parents show little, or no, concern about the child's condition or show little warmth or empathy with the child

• evidence of domestic violence

• parents with mental health difficulties, particularly of a psychotic nature

• evidence of parental substance abuse

 

2.5        Signs and symptoms are indicators and simply highlight the need for further investigation and assessment.

 

              Parental Response to Allegations of Child Abuse Which Raise Concern

 

2.6        Parents' responses to allegations of abuse of their child are very varied. The following types of response are of concern:

 

• there may be an unequivocal denial of abuse and possible non-compliance with enquiries.

 

• parents may over-react, either aggressively or defensively, to a suggestion that they may be responsible for harm to their child.

 

• there may be reluctance to give information, or the explanation given may be incompatible with the harm caused to the child, or explanations may change over time.

 

• parents may display a lack of awareness that the child has suffered harm, or that their actions, or the actions of others, may have caused harm.

 

• parents may seek to minimise the severity of the abuse, or not accept that their actions constitute abuse.

 

• parents may fail to engage with professionals.

 

• blame or responsibility for the harm may be inappropriately placed on the child or an unnamed third party.

 

• parents may seek help on matters unrelated to the abuse or its causes (this may be to deflect attention away from the child and his injuries).

 

• the parents and/or child may go missing.

 

Physical Abuse

 

2.7        Children receive bumps and bruises as a result of the rough and tumble of normal play. Most children will have bruises or other injuries, therefore, from time to time. These will be accidental and can be easily explained.

 

2.8        It is not necessary to establish intent to cause harm to the child to conclude that the child has been subject to abuse. Physical abuse can occur through acts of both commission and/or omission.

 

2.9        Insignificant but repeated injuries, however minor, may be symptomatic of a family in crisis and, if no action is taken, the child may be further injured. All injuries should be noted and collated in the child’s records and analysed to assess if the child requires to be safeguarded.

 

2.10     If on initial examination the injury is not felt to be compatible with the explanation given or suggest abuse it should be discussed with a senior paediatrician.

 

2.11    A small number of children suffer from rare conditions, e.g. haemophilia or brittle bone disease, which makes them susceptible to bruising and fractures. It is important to remain aware, however, that in such children some injuries may have a non-accidental cause. A "clotting screen" only excludes the common conditions which may cause spontaneous bleeding. If the history suggests a bleeding disorder, referral to a haematologist will be required.

 

Recognition of Physical Abuse

 

1.  Bruises + Soft Tissue Injuries

 

2.12      Common sites for accidental bruising depend on the developmental stage of the               child. They include:

 

• forehead

• crown of head

• bony spinal protuberances

• elbows and below

• hips

• hands

• shins

 

2.13                 Less common sites for accidental bruising include:

 

• Eyes

• Ears

• Cheeks

• Mouth

• Neck

• Shoulders

• Chest

• Upper and Inner Arms

• Stomach

• Genitals

• Upper and Inner Thighs

• Lower Back and Buttocks

• Upper Lip and Frenulum

• Back of the Hands.

 

2.14      Non-accidental bruises may be:

 

• frequent

• patterned, e.g. finger and thumb marks

• in unusual positions, (note developmental level and activity of the child).

 

Research on aging of bruises (from photographs) has shown that it is impossible to accurately age bruises although it can be concluded that a bruise with a yellow colour is more than 18 hours old. Tender or swollen bruises are more likely to be fresh. It is not possible to conclude definitely that bruises of different colours were sustained at different times.

 

The following should give rise to concern e.g.

 

• bruising in a non-mobile child, in the absence of an adequate explanation,

 

• bruises other than at the common sites of accidental injury for a child of that developmental stage,

 

• facial bruising, particularly around the eyes, cheeks, mouth or ears, especially in very young children.

 

• soft tissue bruising, on e.g. cheeks, arms and inner surface of thighs, with no adequate explanation.

 

• a torn upper lip frenulum (skin which joins the lip and gum).

 

• patterned bruising e.g. linear or outline bruising, hand marks (due to grab, slap or pinch may be petechial), strap marks particularly on the buttocks or back.

 

• ligature marks caused by tying up or strangulation.

 

2.15      Most falls or accidents produce one bruise on a single surface, usually a bony protuberance. A child who falls downstairs would generally only have one or two bruises. Children usually fall forwards and therefore bruising is most usually found on the front of the body. In addition, there may be marks on their hands if they have tried to break their fall.

 

2.16      Bruising may be difficult to see on a dark skinned child. Mongolian blue spots are natural pigmentation to the skin, which may be mistaken for bruising. These purplish-blue skin markings are most commonly found on the backs of children whose parents are darker skinned.

 

   b)       Eye Injuries

 

2.17      Injuries which should give cause for concern:

 

• black eyes can occur from any direct injury, both accidental and non-accidental. Determining how the injury occurred is vital, therefore; bilateral "black eyes" can occur accidentally as a result of blood tracking from a very hard blow to the central forehead (Injury should be evident on mid-forehead, bridge of nose). It is rare for both eyes to be bruised separately, accidentally however and at the same time.

 

• sub conjunctival haemorrhage

• retinal haemorrhage.

 

           c)        Burns and Scalds

 

2.18 Accidental scalds often:

 

• are on the upper part of the body

• are on a convex (curved) surface

• are irregular

• are superficial

• leave a recognisable pattern.

 

2.19 It can be difficult to distinguish between accidental and non-accidental burns. Any burn or scald with a clear outline should be regarded with suspicion e.g.

 

• circular burns

• linear burns

• burns of uniform depth over a large area

• friction burns

• scalds that have a line which could indicate immersion or poured liquid

• splash marks

• old scars indicating previous burns or scalds.

 

2.20 When a child presents with a burn or scald it is important to remember:

 

• a responsible adult checks the temperature of the bath before a child gets in to it.

 

• a child is unlikely to sit down voluntarily in too hot water and cannot accidentally scald his bottom without also scalding his feet.

 

• "doughnut" shaped burns to the buttocks often indicate that a child has been held down in hot water, with the buttocks held against the water container e.g. bath, sink etc.

• a child getting into too hot water of its own accord will struggle to get out and there are likely to be splash marks.

 

• small round burns may be cigarette burns, but can often be confused with skin conditions. Where there is doubt, a medical/dermatology opinion should be sought.

 

d)          Fractures

 

2.21      The potential for a fracture should be considered if there is pain, swelling and discoloration over a bone or joint or a child is not using a limb, especially in younger children. The majority of fractures normally cause pain and it is very difficult for a parent to be unaware that a child has been hurt. In infants, rib and metaphysical limb fractures may produce no detectable ongoing pain however.

 

2.22        It is very rare for a child aged under one year to sustain a fracture accidentally, but there may be some underlying medical condition, e.g. brittle bone disease, which can cause fractures in babies.

 

2.23         The most common non-accidental fractures are to the long bones in the arms and legs and to the ribs. The following should give cause for concern and further investigation may be necessary:

 

• any fracture in a child under one year of age

• any skull fracture in children under three years of age

• a history of previous skeletal injuries which may suggest abuse

• skeletal injuries at different stages of healing

• evidence of previous fractures which were left untreated.

 

              e)          Scars

 

2.24                    Children may have scars from previous injuries. Particular note should be taken if there is a large number of scars of different ages, or of unusual shapes or large scars from burns or lacerations that have not received medical treatment.

              f)           Bites

 

2.25                    Bites are always non-accidental in origin; they can be caused by animals or human beings (adult/child); a dental surgeon with forensic experience may be needed to secure detailed evidence in such cases.

 

g)                         Other Types of Physical Injuries

1.  

• poisoning, either through acts of omission or commission 

• ingestion of other damaging substances, e.g. bleach

• administration of drugs to children where they are not medically indicated or prescribed

• female genital mutilation, which is an offence, regardless of cultural reasons

•         unexplained neurological signs and symptoms, e.g. subdural haematoma

 

              h)          Fabricated or Induced Illness

 

2.27                    Fabricated or induced illness, previously known as Munchausen's Syndrome by Proxy, is a condition where a child suffers harm through the deliberate action of the main carer, in most cases the mother, but which is attributed to another medical cause.

 

2.28                    It is important not to confuse this deliberate activity with the behaviour and actions of over-anxious parents who constantly seek advice from doctors, health visitors and other health professionals about their child's wellbeing.

 

2.29                    There is a need to exercise caution about attributing a child's illness, in the absence of a medical diagnosis, to deliberate activity on the part of a parent or carer to a fabricated or induced illness, as stated in the Court of Appeal judgement in the case of Angela Cannings.

 

(R v Cannings (2004) EWCA Criml (19 January 2004)).

 

2.30                    The following behaviours exhibited by parents can be associated with fabricated or induced illness:

 

• deliberately inducing symptoms in children by administering medication or other substances, or by means of intentional suffocation.

• interfering with treatments by over-dosing, not administering them or interfering with medical equipment such as infusion lines or not complying with professional advice, resulting in significant harm.

• claiming the child has symptoms which may be unverifiable unless observed directly, such as pain, frequency of passing urine, vomiting or fits.

• exaggerating symptoms, causing professionals to undertake investigations and treatments which may be invasive, unnecessary and, therefore, are harmful and possibly dangerous.

• obtaining specialist treatments or equipment for children who do not require them.

• alleging psychological illness in a child.

 

2.31                    There are a number of presentations in which fabricated or induced illness may be a possibility. These are:

 

• failure to thrive/growth faltering (sometimes through deliberate withholding of food.)

• fabrication of medical symptoms especially where there is no independent witness

• convulsions.

• pyrexia (high temperature).

• cyanotic episode (reported blue tinge to the skin due to lack of oxygen).

• apnoea (stops breathing).

• allergies

• asthmatic attacks

• unexplained bleeding (especially anal or genital or bleeding from the ears)

• frequent unsubstantiated allegations of sexual abuse, especially when accompanied by demands for medical examinations

• frequent ‘accidental’ overdoses (especially in very young children).

 

2.32                   Concerns may arise when:

 

• reported symptoms and signs found on examinations are not (3 explained by any medical condition from which the child may be suffering.

• physical examination and results of medical investigations do not explain reported symptoms and signs.

• there is an inexplicably poor response to prescribed medication and other treatment.

• new symptoms are reported on resolution of previous ones.

• reported symptoms and/or clinical signs do not occur when the carers are absent

• over time the child is repeatedly presented to health professionals with a range of signs and symptoms.

• the child's normal, daily life activities are being curtailed beyond that which might be expected for any medical disorder or disability from which the child is known to suffer.

 

2.33                    It is important to note that the child may also have an illness that has been diagnosed and needs regular treatment. This may make the diagnosis of fabricated or induced illness difficult, as the presenting symptoms may be similar to those of the diagnosed illness.

 

                            Sexual Abuse

 

2.34                    Most child victims are sexually abused by someone they know, either a family member or someone well known to them or their family. In recent years there has been an increasing recognition that both male and female children and older children are sexually abused to a greater extent than had previously been realised.

 

2.35                    There are no 'typical' sexually abusing families. Children who have been sexually abused are likely to have been put under considerable pressure not to reveal what has been happening to them. Sexual abuse is damaging to children, both in the short and long term.

 

2.36                    Both boys and girls of all ages are abused and the abuse may continue for many years before it is disclosed. Abusers may be both male and female.

 

2.37                    It is important to note that children and young people may also abuse other children sexually.

2.38                    Children disclosing sexual abuse have the right to be listened to and to have their allegations taken seriously. Research shows it is rare for children to invent allegations of sexual abuse and that in fact they are more likely to claim they are not being abused when they are.

2.39                    It is important that the indicators listed below are assessed in terms of significance and in the context of the child's life, before concluding that the child is, or has been, sexually abused.

 

                            Some indicators take on a greater, or lesser, importance depending upon the child's age.

​

              Recognition of Sexual Abuse

2.40                    Sexual abuse often presents in an obscure way. Whilst some child victims have obvious genital injuries, a sexually transmitted infection or are pregnant, relatively few children are so easily diagnosed. The majority of children subjected to sexual abuse, even when penetration has occurred, have on medical examination no evidence of the abuse having occurred.

2.41                    The following indicators of sexual abuse may be observed in a child. There may be occasions when no symptoms are present but it is still thought that a child may be, or has been, sexually abused. Suspicions increase where several features are present together. The following list is not exhaustive and should not be used as a check list.

 

 

2.43                    Possible behavioural indicators include:

 

• unusual behaviour associated with the changing of nappy/underwear, e.g. fear of being touched/hurt, holding legs rigid and stiff or verbalisation like "stop hurting me".

 

• heightened genital awareness - touching, looking, verbal references to genitals, interest in other children's or adults' genitals.

 

• using objects for masturbation - dolls, toys with phallic-like projections.

 

• rubbing genital area on an adult - wanting to smell genital area of an adult, asking adult to touch or smell their genitals.

 

• simulated sexual activity with another child e.g. replaying the sexually abusive event or wanting to touch other children etc.

 

• simulated sexual activity with dolls, cuddly toys.

 

• fear of being alone with adult persons of a specific sex, especially that of the suspected abuser.

 

• self-mutilation e.g. picking at sores, sticking sharp objects in the vagina, head banging etc.

 

• social isolation - the child plays alone and withdraws into a private world.

 

• inappropriate displays of affections between parent and child who behave more like lovers.

 

• fear of going to bed and/or overdressing for bed.

 

• child takes over 'the mothering role' in the family whether or not the mother is Possible      

                           

 

The Adolescent

 

2.45                    In addition to the physical indicators previously outlined in the preschool and pre-adolescent child, the following indicators relate specifically to the adolescent:

 

• recurrent urinary tract infections.

 

• pregnancy, especially where the information about or the identity of the father is            vague or secret or where there is complete denial of the pregnancy by the girl and      her family.

 

• sexually transmitted infections.