Signs and Symptoms of Abuse - Additional Information

 

Signs and Symptoms of Abuse
 

1. Signs and Symptoms of Child Neglect
This category of abuse is the most common. A distinction can be made between 'willful' neglect and 'circumstantial' neglect. For instance, 'willful' neglect would generally incorporate a direct and deliberate deprivation by a parent or caregiver of a child's most basic needs e.g. withdrawal of food, shelter, warmth, clothing, contact with others. Whereas 'circumstantial' neglect more often may be due to stress/inability to cope by parents or caregiver. Neglect is closely correlated with low socio-economic factors and corresponding physical deprivations. It is also related to parental incapacity due to learning disability or psychological deprivations. It is also related to parental incapacity due to learning disability or psychological disturbance.

The neglect of children is 'usually a passive form of abuse involving omission rather than acts of commission'. It comprises 'both a lack of physical caretaking and supervision and a failure to fulfill the developmental needs of the child in terms of cognitive stimulation'.*

[* Skuse, D. and Bentovim, A. (1994) “Physical and Emotional Maltreatment”. In Rutter, M. Taylor, E.
and Hersor, L. (Editors), Child and Adolescent Psychiatry (Third Edition), Oxford:
Blackwell Scientific Publications.]

Child neglect should be suspected in cases of:

• Abandonment or desertion

• Children persistently being left alone without adequate care and supervision

• Malnourishment, lacking food, inappropriate food or erratic feeding

• Lack of warmth

• Lack of adequate clothing

• Lack of protection and exposure to danger including moral danger or lack of supervision appropriate to the child's age

• Persistent failure to attend school

• Non-organic failure to thrive i.e. child not gaining weight not alone due to malnutrition but also due to emotional deprivation

• Failure to provide adequate care for the child's medical problems

• Exploited, overworked.

2. Signs and Symptoms of Emotional Child Abuse
Emotional abuse occurs when adults responsible for taking care of children are unable to be aware of and meet their children's emotional and developmental needs. Emotional abuse is not easy to recognize because the effects are not easily observable. 'Emotional abuse refers to the habitual verbal harassment of a child by disparagement, criticism, threat and ridicule and the inversion of love; whereby verbal and non-verbal means of rejection and withdrawal are substituted.' **

** Skuse D. (1989) “Emotional Abuse and Neglect” in Meadow, R. “ABC of Child Abuse”, British Medical Journal Publications, London.

Emotional abuse can be defined in reference to the following indices. However, it should be noted that no one indicator is conclusive of emotional abuse.

• Rejection

• Lack of praise and encouragement

• Lack of comfort and love

• Lack of attachment

• Lack of proper stimulation (e.g. fun and play)

• Lack of continuity of care (e.g. frequent moves)

• Serious over-protectiveness

• Inappropriate non-physical punishment (e.g. locking in bedrooms)

• Family conflicts and/or violence

• Every child who is abused sexually, physically or neglected is also emotionally abused

• Inappropriate expectations of a child's behavior - relative to his/her age and stage of development.
   

3. Signs and Symptoms of Physical Abuse
Unsatisfactory explanations or varying explanations for the following events are highly suspicious:

• Bruises (see below for more detail)

• Fractures

• Swollen joints

• Burns and Scalds (see below for more detail)

• Abrasions and Lacerations

• Hemorrhages (retinal, subdural)

• Damage to body organs

• Poisonings - repeated (prescribed drugs, alcohol)

• Failure to thrive

• Coma/Unconsciousness

• Death

There are many different forms of physical abuse but skin, mouth and bone injuries are the most common.

Bruises - in general
Accidental bruises are common at places on the body where bone is fairly close to the skin. Bruises can also be found towards the front of the body, as the child usually will fall forwards.

Accidental bruises are common on the chin, nose, forehead, elbow, knees and shins. An accident-prone child can have frequent bruises in these areas. Such bruises will be diffuse with no definite edges. Any bruising on a child before the age of mobility must be treated with concern.

Suspicion
Bruises are more likely to occur on soft tissues e.g. cheek, buttocks, lower back, back or thighs and calves, neck, genitalia and mouth.

Bruises - non-accidental
Marks from slapping or grabbing may form a distinctive pattern. Slap marks might occur on buttocks or cheeks and the outlining of fingers may be seen on any part of the body. Bruises may be associated with shaking which can cause serious hidden bleeding and bruising inside the skull.

Any bruising around the neck is suspicious as it is very unlikely to be accidentally acquired. Bruises caused by direct blows with a fist have no definite pattern but may occur in parts of the body which do not usually receive injuries by accident. A punch over the eye (black eye syndrome) or ear would be of concern. Black eyes cannot be caused by a fall onto a flat surface. Two black eyes require two injuries and must always be suspect.

Other injuries may feature - ruptured eardrum or fractured skull. Mouth injury may be a cause of concern - torn mouth (frenulum) from forced bottle-feeding. Other distinctive patterns of bruising may be left by the use of straps, belts, sticks and feet. The outline of the object may be left on the child in a bruise on areas such as back, thighs (areas covered by clothing).

Burns - in general
Children who have accidental burns usually have a hot liquid splashed on them by spilling or have come into contact with a hot object. The history that parents give is usually in keeping with the pattern of injury observed. However, repeated episodes may suggest inadequate care and attention to safety within the house.

Burns - non-accidental
Children who have received non-accidental burns may exhibit a pattern that is not adequately explained by parents. The child may have been immersed in a hot liquid. The burn may show a definite line, unlike the type seen in accidental splashing. The child may also have been held against a hot object like a radiator or a ring of a cooker leaving distinctive marks. Cigarette burns may result in multiple small lesions in places on the skin that would not generally be exposed to danger. There may be other skin conditions that can cause similar patterns and expert pediatric advice should be sought.

Bites - in general
Children can get bitten either by animals or humans. Animal bites, e.g. dogs - commonly puncture and tear the skin and usually the history is definite. Small children can also bite other children.

Bites - non accidental
It is sometimes hard to differentiate between adults' and children’s' bites as measurements can be inaccurate. Any suspected adult bite mark must be taken very seriously. Consultant Pediatricians may liaise with Dental colleagues in order to correctly identify marks.

Bone injuries - in general
Children regularly have accidents that result in fractures. However, children's bones are more flexible than those of adults and the children themselves are lighter, so a fracture, particularly of the skull, usually signifies that considerable force has been applied.

Bone injuries - non-accidental
A fracture of any sort should be regarded as suspicious in a child under 8 months of age. A fracture of the skull must be regarded as particularly suspicious in a child under 3 years. Either case requires careful investigation as to the circumstances in which the fracture occurred. Swelling in the head or drowsiness may also indicate injury.

Poisoning - in general
Children may commonly take medicines or chemicals that are dangerous and potentially life threatening. Aspects of care and safety within the home need to be considered with each event.

Poisoning - non-accidental
Non-accidental poisoning can occur and may be difficult to identify but should be suspected in bizarre or recurrent episodes and when more than one child is involved. Drowsiness or hyperventilation may be a symptom.

Shaking violently
Shaking is a frequent cause of brain damage in very young children.
 

4. Signs and Symptoms of Child Sexual Abuse
Child sexual abuse often covers a wide spectrum of abusive activities. It rarely involves just a single incident and usually occurs over a number of years. Child sexual abuse frequently happens within the family. Intra-familial abuse is particularly complex and difficult to deal with.

Cases of sexual abuse principally come to light through:

• disclosure by the child or its siblings/friends;

• the suspicions of an adult;

• due to physical symptoms.

Colburn Faller* provides a description of the wide spectrum of activities by adults which can constitute child sexual abuse. These include:

Non contact sexual abuse

• 'Offensive Sexual Remarks' including statements the offender makes to the child regarding the child's sexual attributes, what he or she would like to do to the child and other sexual comments.

• Obscene Phone-calls.

• Independent 'exposure' involving the offender showing the victim his or her private parts or masturbating in front of the victim.

• 'Voyeurism' involving instances when the offender observes the victim in a state of undress or in activities that provide the offender with sexual gratification. These may include activities that others do not regard as even remotely sexually stimulating.

Sexual contact

• involving any touching of the intimate body parts. The offender may fondle or masturbate the victim and/or get the victim to fondle and/or masturbate them. Fondling can be either outside or inside clothes. Also includes 'frottage', i.e. where offender gains sexual gratification from rubbing his/her genitals against the victim's body or clothing.

• Oral-genital sexual abuse
  Involving the offender licking, kissing, sucking or biting the child's genitals or inducing the child to do the same to them.

Interfemoral sexual abuse

• sometimes referred to as 'dry sex' or 'vulvar intercourse', involving the offender placing his penis between the child's thighs.

Penetrative sexual abuse of which there are four types

• 'digital penetration' involving putting fingers in the vagina, or anus or both. Usually the victim is penetrated by the offender, but sometimes the offender gets the child to penetrate them.

• 'penetration with objects' involving penetration of the vagina, anus or occasionally mouth with an object.

• 'genital penetration' involving the penis entering the vagina, sometimes partially.

• 'anal penetration' involving the penis penetrating the anus.

[*Colbourn Faller, K. (1989) “Child Sexual Abuse”. An Interdisciplinary Manual for Diagnosis Case Management and Treatment. Basingstoke: Macmillian.]

Sexual exploitation

• Involves situations of sexual victimization where the person who is responsible for the exploitation may not have direct sexual contact with the child. Two types of this abuse are child pornography and child prostitution.

• 'Child pornography' includes still photography, videos and movies and, more recently computer generated pornography.

• 'Child Prostitution' for the most part involves children of latency age or in adolescence. However, children as young as four and five are known to be abused in this way.

• Sexual abuse in combination with other abuse.

• The sexual abuses described above may be found in combination with other abuses, such as physical abuse and urination and defecation on the victim. In some cases physical abuse is an integral part of the sexual abuse; in others drugs and alcohol may be given to the victim.

It is important to note that physical signs may not be evident in cases of sexual abuse due to the nature of the abuse or the fact that the disclosure was made some time after the abuse took place.

Caregivers and professionals should be alert to the following physical and behavioral signs:

• Bleeding from the vagina or anus

• Difficulty or pain in passing urine or feces

• An infection may occur secondary to sexual abuse, which may or may not be a definitive sexually transmitted disease. Professionals should be informed if a child has a persistent vaginal discharge or has warts or rash in genital area.

• Noticeable and uncharacteristic change of behavior

• Hints about sexual activity

• Age - inappropriate understanding of sexual behavior

• Inappropriate seductive behavior

• Sexually aggressive behavior with others

• Uncharacteristic sexual play with peers or toys

• Unusual reluctance to join in normal activities which involve undressing, e.g. games or swimming.

Particular behavioral signs and emotional problems suggestive of child abuse in young children

(0-10 yrs):

• Mood change, e.g. child becomes withdrawn, fearful, acting out

• Lack of concentration (change in school performance)

• Bed wetting, soiling

• Psychosomatic complaints; pains, headaches

• Skin disorders

• Nightmares, changes in sleep patterns

• School refusal

• Separation anxiety

• Loss of appetite

• Isolation

Particular behavioral signs and emotional problems suggestive of child abuse in older children

(10 yrs +):

• Mood change, e.g. depression, failure to communicate

• Running away

• Drug, alcohol, solvent abuse

• Self-mutilation

• Suicide attempts

• Delinquency

• Truancy

• Eating disorders

• Isolation

Note: All signs and indicators need careful assessment relative to
the child's circumstances