Child abuse and domestic violence - cutaneous features

All health care professionals should be competent in child protection as well as having a good awareness of domestic violence. This chapter, which is set out as below, serves to highlight the salient features of these topics.

• Bumps and bruises don’t necessarily mean a child is being physically abused - all children have accidents, trips and falls. There isn’t one sign or symptom to look out for that will say a child is definitely being physically abused. But if a child often has injuries, there seems to be a pattern, or the explanation doesn’t match the injury then this should be investigated
   
• The section below discusses:
  • Child abuse: non-accidental injury (NAI)
  • Fabricated or induced illness
  • Domestic violence

Child abuse: non-accidental injury 

Features suggesting non-accidental injury include:

• A history that is ’hollow’ with a lack of detail

• Risk factors include single or young parents, poverty, frequent visits to the GP or accident and emergency departments, previous abuse

• General clues
  • Poor hygiene
  • Dressed inappropriately for the weather
  • Failure to thrive
     
• Bruising is the most common manifestation of physical abuse, occurring in one study in 52% of affected individuals
• Any bruising in a non-ambulatory baby (or child) 
• Site of bruises
  • Commonly on the head especially the sides of the face, the ears, and black eyes
  • The buttocks/lower back and outer thighs - these are the ’punishment’ sites
  • Clusters of bruises on the upper arm
  • Inner thighs and genitalia
• Multiple bruises in various stages of healing, especially on the trunk
• Colour of bruises is not reliable for dating - documentation of colours is important
• Hand prints or oval finger marks
• Belt marks - a long broad band ending with horseshoe shape or puncture from buckle
• Loop pattern from cord, rope or wire that has been doubled up
• Ligature pattern on neck, wrists, ankles
• Gag pattern on corners of the mouth

• Burns are seen in 6-20% of abused children
• Is the severity of the burn consistent with length of contact by history?
• Are the burns the shape of a hot object?
• Cigarette burns - circular, 8-10 mm deep, heaped margin. Can be confused with impetigo
• Immersion burns have a sharp line of demarcation without drip or splash marks
• Stun gun burns occur in pairs, 0.5 cm diameter and 5 cm apart 

• Other cutaneous features 
  • Facial injuries without good explanation
  • Traumatic hair loss
  • Oral/dental injuries, such as torn or bruised frenulum, lips, teeth, palate, tongue or oral mucosa
  • Bites - human bites are more superficial than animal, and show up better 2-3 days later
  • Defensive injuries on forearms
  • Lacerations
  • Signs of restraints on axilla or extremities
  • Injuries from non-ambulatory child may be include ''bottle jamming"
     
• Non-cutaneous features 
  • Fractures
  • Bruising, tearing, bleeding, or discharge from genital or rectal area
  • Diagnosed STD or pregnancy
  • Psychological symptoms

Fabricated or induced illness

• Fabricated or induced illness (FII) is a rare form of child abuse. It occurs when a parent or carer, usually the child’s biological mother, exaggerates or deliberately causes symptoms of illness in the child. FII is also known as Munchausen's syndrome by proxy

• The National Institute for Health and Care Excellence states that fabricated or induced illness may first be suspected if physical or psychological examination and diagnostic tests do not explain the reported signs and symptoms, and, when one or more of the following warning signs are present:

  • Symptoms only appear when the parent or carer is present
  • The only person claiming to notice symptoms is the parent or carer
  • The affected child has an inexplicably poor response to medication or other treatment
  • If a particular health problem is resolved, the parent or carer suddenly begins reporting a new set of symptoms
  • The child's history of symptoms does not result in expected medical outcomes - for example, a child who has supposedly lost a lot of blood but doesn't become unwell
  • The parent or carer has a history of frequently changing GPs or visiting different hospitals for treatment, particularly if their views about the child’s treatment are challenged by medical staff
  • The child’s daily activities are being limited far beyond what you would usually expect as a result of having a certain condition - for example, they never go to school or have to wear leg braces even though they can walk properly 

Domestic violence

While every domestic abuse case is different, there may be telltale signs that indicate abuse is taking place. These include:

• Injuries - bruising, cuts, walking stiffly or appears in discomfort. These injuries may come with explanations that don’t fit with the description

• Clothing - patient's dress in clothes designed to hide bruises or scars (eg wearing long sleeves in the summer or sunglasses indoors)

• Excuses - the victim may excuse their injuries by claiming they are clumsy or gives the same explanation each time

• Absent from work - often off work, takes time off without notice or is frequently late

• Stress - displays physical symptoms related to stress, other anxiety disorders such as panic attacks, depression and an inability to cope. The patient may even talk about suicide attempts or self-harming

• Low self-esteem - low self-esteem or lack of confidence regarding their relationship or life in general and may seem sad, cry or be depressed

• Self-blame - may take the blame for anything that happens, whether it’s at work, with the kids or with friends. They may blame themselves for the abuse

• Stops socialising - makes excuses for not going out with friends, or suddenly pulls out of social meets at the last minute

• Personality change - you may notice a personality change when the victim is around their partner, appearing to ‘walk on eggshells’, be jumpy or nervous

• Lack of opportunity to communicate independently - perhaps their partner talks over them, or for them. Their partner may appear controlling or regularly belittle the victim

• Partner displays irrational behaviour - their partner is jealous, irrational or possessive. Their partner may accuse them of having affairs, flirting or may read their emails, check their phone or constantly phone to check up on them

• Lack of money - never seems to have any money because their partner is withholding money to control them

• Unwanted pregnancy/termination - pregnancy often triggers the start of domestic abuse. She may be unhappy at being pregnant, not wish to continue with the pregnancy, or be forced into having a termination

• Substance abuse - may use alcohol or drugs to cope, or even prescribed drugs such as tranquillisers or anti-depressants

• Unwilling to give out personal details - may not give friends and colleagues their address or telephone number and may insist that they contact you, so that you don’t turn up on their doorstep

• Damage to property - there may be damage to the home or even harm to pets

• Child abuse is preventable - not inevitable, indeed so is domestic violence

• It is up to each of us to do everything possible to keep childhood safe from abuse, so children can grow up healthy and thrive

• However, if child abuse is suspected it is important that health professionals follow local safeguarding procedures without delay

• We must also do the same to support victims of  domestic violence, and where there is domestic violence there may also be child abuse