Children who have been maltreated may present to the primary care practitioner (GMO) in the outpatient clinic or emergency room. When asked how the injury occurred, the caretaker may have no explanation, may sound as if the story is rehearsed, may change the story over time with repeated interviews (inconsistencies), may describe an accident that does not adequately explain the child's injuries, or may describe the child doing something that is developmentally impossible.

Assessing caretaker behavior is important when evaluating a child for suspected abuse. Delay in seeking appropriate medical treatment for the child's injuries is a worrisome sign. The parents may have little knowledge of normal developmental stages, or have unrealistic expectations of the child or both. They may describe the child in negative terms or blame the child for causing trouble. Inability to plan or to focus on their own feelings as well as social isolation is frequently present in these families.

Some specific signs of physical abuse are bruises or welts about the face or head, on the trunk, back, thighs, or genitals. The skin findings are often on multiple body surfaces or planes and may be in the shape of a hand or objects such as a belt or electrical cord. Any bruises in non-ambulatory infants are highly suspicious. Burns and scalding, usually second or third degree, may result from immersion, non-accidental splashing of hot liquids, or contact with hot objects, e.g., irons, heaters, or cigarettes. Fractures, especially bucket-handle or corner fractures (metaphyseal fractures), rib fractures, scapular fractures, vertebrae fractures, spiral fractures in nonweight bearing infants, or multiple fractures in various stages of healing should be regarded as strongly suggestive of physical abuse. Subdural, subarachnoid, and retinal hemorrhages with or without skull fractures that cannot be explained by history are most strongly suggestive of non-accidental trauma.

The shaken-impact (shaken baby) syndrome is not an uncommon form of abuse but often results in significant morbidity (developmental disabilities) or mortality. Symptoms and signs of shaken baby syndrome may vary from irritability, lethargy, poor feeding, vomiting (without diarrhea), or temperature instability, to profound effects such as gasping respirations or apnea, acute loss of consciousness, seizures, or even death. These infants frequently have intracranial bleeding (especially subdural) and retinal hemorrhages. If this is suspected, the following evaluation should be performed:

• Head CT or MRI,
• Skeletal survey (perhaps a bone scan), and
• An ophthalmology consult.

A skeletal survey must be done in all suspected cases of child abuse and neglect in children less than two years old. This should include AP views of the upper arms, lower arms, thighs, lower legs, hands and feet; AP and lateral views of the chest, spine, and skull – all on separate sheets of x-ray film. These films should be read by a pediatric radiologist if at all possible.

Child Neglect

Child neglect, another form of maltreatment, is the deprivation of necessities including food, shelter, clothing, health care, education, or appropriate supervision when these could be provided by the guardians. Child neglect is as lethal as physical abuse. Some studies show that as many children die from neglect as from physical abuse. Indicators of neglect include lack of appropriate child supervision, lack of medical attention (e.g., immunizations not up to date) and often developmental lag.

Emotional Maltreatment

Emotional maltreatment may be the result of psychologic unavailability of the caretaker. These children often suffer frequent humiliation and scapegoating. Parents may show inconsistent or unrealistic expectations or both. Acute manifestations of emotional abuse include increased worries, fears, and phobias, somatic complaints, and nightmares. If emotional abuse becomes chronic, the child may exhibit failure to thrive, low self-esteem, poor peer relationship, impulse disorders, and school problems.

Indicators of abuse

Child sexual abuse (also see separate section) is defined as the involvement of a child in any act or situation, the purpose of which is to provide sexual gratification or financial benefit for the perpetrator. While it often involves physical contact (e.g., fondling, penetration), child sexual abuse may also involve behavior such as showing a child pornographic material or exhibiting one's genitals to a child. Physical indicators of sexual abuse can include bruises or bleeding in the genitourinary and anal area, recurrent urinary tract infections, vaginal discharge, and sexually transmitted disease (STD). Behavioral indicators of child sex abuse include shame or guilt, sexually explicit play, problems in school, enuresis and encopresis, nightmares, depression, and pseudomaturity. Runaway behavior, promiscuity, substance abuse, and suicidal ideations in adolescents may also be indicators of abuse.

While sexual abuse may be discovered through routine examinations or examination due to some trauma or infection, it most often endures over long periods of time leaving no physical evidence of harm. The most significant indicator of sexual abuse is the child's own report. Children rarely lie about sexual abuse, and it is critical to believe them. In cases where there has been no harm, and the findings are congruent with the child's story, it is important that the medical report recognize this consistency.

General guidance

The role of medical personnel (including the GMO) in the multidisciplinary assessment of suspected abuse includes learning the indicators that help to identify child maltreatment, documentation of the clinical findings, treatment and protection of the child, and reporting concerns to appropriate authorities. The GMO must take an active role in identification of maltreatment and document fully, and in detail, both physical and behavioral findings, using descriptive, nonjudgmental language. Record accurately what the victim and others say and, where appropriate, draw pictures of the injuries as well as take photographs.

The physician has a mandatory responsibility to report suspected cases of maltreatment to the family advocacy representative (FAR) as well as to the civilian child protective service agency (CPS), if one is available. After receiving the report, the FAR notifies relevant Naval Criminal Investigative Service (NCIS), legal, and civilian officials.

An investigation of the incident will be done, and the findings presented by the FAR to the Child Abuse Case Review Committee (Child CRC) and the civilian CPS agency will make the final determination on the validity of the report. Recommendations for treatment and other interviews will be made by the CRC and the FAR or a case manager will monitor the case. Periodic reviews of open cases will be done by the CRS to ensure recommendations are being carried out before the case is closed. For details of the above process, see the DoD and DON instructions in the reference section.

For questions concerning medical aspects of suspected child maltreatment, the following consultative service is available:

The Armed Forces Center for Child Protection
National Naval Medical Center, Bethesda, Maryland
Commercial: (301) 295-4100
DSN: 295-4100
Toll-free CONUS: (877) 295-4100
Toll-free OCONUS: (877) 270-2492
FAX: (301) 295-2657

References

1. Wissow, L.S., Child Advocacy of the Clinician: an approach to child abuse and neglect. Baltimore, Maryland: William & Wilkins, 1990.
2. DoD directive 6400.1 dated 23 Jun 92
3. OPNAVINST 1752.2
4. SECNAVINST 1752.3
5. NAVMEDCOMINST 6320.22

Revised by CAPT Barbara R. Craig, MC, USN, Medical Consultant for Child Abuse and Neglect, The Armed Forces Center for Child Protection, National Naval Medical Center, Bethesda, MD (1999).