ABC of Child Abuse

NON-ACCIDENTAL INJURY,Nigel Speight

Child abuse is the difference between a-handon the bottom and a fist in the face.:

HENRY KEMPE

Difficulty of diagnosisThe diagnosis of physical abuse (non-accidentalinjury) is a difficult intellectual and emotionalexercise. It is one of the most difficult subjects inclinical Work, needing time, experience, andemotional energy. The biggest barrier todiagnosis is the existence of emotional blocks inthe minds of professionals. These can be so

Dr Nigel Speight, FRCP, is powerful that theyprevent the diagnosis evenconsultant paediatrician to being considered in quite obvious cases (see, forDurham and North.West example, case 1).Durham health autforities. All those working with children should beThe ABC of Clinical warned that their overwhelming impulse on

week.nThethirdarltile inex confronting their first case will be to want to coverweek. The third article inthis series will appear on it up.15 April. The most important step in diagnosing

non-accidental injury is to force yourself to thinkof it in the first place.

Importance of diagnosisNon-accidental injury is one of the most

important diagnoses in clinical paediatrics as itcan so vitally influence a child's future life. Atworst it is a matter of life and death for the child,and short of death there may still be possiblebrain damage or handicap. Though high riskcases are currently in a minority, the diagnosisremains crucially important in every case. This isbecause non-accidental injury is often a markerfor emotional abuse and deprivation that cancause progressive and possibly permanentdamage to a child's developing personality. Thisprinciple is especially relevant in children ofschool age. In such children the risk of death maybe extremely small, yet non-accidental injury inolder children is almost inevitably associated witha longstanding disturbance of the parent-childrelationship. For this reason non-accidentalinjury should never be dismissed as"overchastisement."

Non-accidental injury is not a full diagnosis, itis merely a symptom of disordered parenting.The aim ofintervention is to diagnose and cure (ifpossible) the disordered parenting. Simply to aimat preventing death is a lowly ambition.

In some cases the occurrence of physical abusemay provide an opportunity for intervention. Ifthis opportunity is missed there may be nofurther opportunity for many years.

Diagnostic featuresThere are no hard and fast rules and no easy

answers for diagnosis. The following listconstitutes seven classic "pointers" to thediagnosis. None of them is diagnostic, neitherdoes the absence of any of them exclude thediagnosis of non-accidental injury.

(1) There is a delay in seeking medical help (ormedical help is not sought at all).

(2) The story of the "accident" is vague,-islacking in detail, and may vary with each tellingand from person to person. (Innocent accidentstend to have vivid accounts that ring true.)

(3) The account of the accident is notcompatible with the injury observed.

(4) The parents' affect is abnotnal. Normalparents are full of creative anxity for the child.Abusing parents tend to be more preoccupiedwith their owv probleis-for exampie, how theycan return home as soon as p6ssible.

(5) The parents' behaviour gives cause for,

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Case 1: The importance ofwhat the child says

This 4 year old girl had been "rehabilitated" under a care order eight monthspreviously. She was bro'ught to hospital with a fractured femur. Her fatherclaimed that she had fallen down stairs, and despite the excessive bruising onher thigh and buttocks and her abject appearance no questions were asked.The next morning she told a nurse, "Daddy toldMummy he would never do itagain." On further questioning the father became aggressive and had to berestrained by police from abducting the child after attempting to remove herGallow's traction.

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concern-for example, they soon become hostile,they rebut accusations that have not been made,and they leave before the consultant arrives.

(6) The child's appearance and his interactionwith his parents is abnormal. He may look sad,withdrawn, or frightened (case 2). There may bevisible evidence of a failure to thrive. Full blownfrozen watchfulness is a late stage and resultsfrom repetitive physical and emotional abuseover a period of time. The absence of frozenwatchfulness does not exclude the diagnosis ofnon-accidental injury.

(7) The child may say something (case 1).Always make a point of interviewing the child (ifold enough) in a safe place in private. This is oneof the virtues of admission to hospital.Interviewing the child as an outpatient may fail tolet the child open up as he is expecting to bereturned to the custody of the abusing parent inthe near future.

Characteristic patterns of injurySome forms of injury are by'their nature

virtually diagnostic of non-accidental injury.These include finger tip bruising, especiallywhen it is multiple (cases 3 and 4); cigaretteburns; lash marks (case 5); retinal and subduralhaemorrhages (figure), which can occur after ashaking injury without other evidence ofbruisingor fracture; and a torn frenulum.

How to approach a case of suspectednon-accidental injury

Firstly, approach the parents as you would inany other clinical case. Introduce yourself, shakehands, and proceed logically through the history,examination, provisional diagnosis, and decisionmaking.

Secondly, do not jump to conclusions one wayor the other. Try to proceed slowly anddeliberately, keeping your mind open as long aspossible. Take a provisional social history to forma picture of the family's background and howlikely it would be for abuse to occur there.

Referral pathwayThe diagnosis of non-accidental injury is a two

tier exercise. The doctor on the front line (generalpractitioner, senior house officer in the accidentand emergency department, or school doctor) isresponsible for identifying children withsuspected physical abuse and referring them to aconsultant paediatrician for definitive diagnosis.

Role offront line doctorsDoctors on the front line must realise and

accept the limits of their responsibility. They donot have to make a definitive diagnosis andshould have a comparatively low threshold ofreferral. It should be accepted that some children

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Case 2: The importance ofthe child's appearanceThese pictures show the "before and after" effect whensevere deprivation is reversed. This 3 year old boy was infact never subjected to non-accidental injury, but manychildren in cases of non-accidental injury may have thesame appearance. He was admitted after a genuineaccident and noted to be extremely deprived. The bondbetween him and his mother was non-existent. (He hadbeen admitted two years before with non-organic failure tothrive and retardation but allowed to lapse from medicalfollow up with no referral to social services.) I-n the wardhe showed noticeable affection-seeking behaviour andflourished. The follow up photograph was taken sixmonths later while he was in foster care.

Case 3: Fingertip bruisingand fractured ribsThis 4 month old baby wasnoted to have two bruises onthe cheek highly suggestive offinger tip bruising fromforceful gripping. A skeletalsurvey showed two healing ribfractures caused by an episodefour to eight weeks previously.

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Injury observed

Flow chartfor referral ofcases ofsuspected non-accidental injury (NAI)

Retinal haemorrhagefrom non-accidental injury

with innocent injuries will be referred. Ifall ofthechildren referred turn out to have been physicallyabused the threshold for referral is almostcertainly too high.

Front line doctors should not feel guilt aboutreferring children with suspected non-accidentalinjury to a paediatrician. They are not accusingeither parent; they are simply asking for a secondopinion on an important and difficult diagnosis.The fact that the child is being referred because ofsuspected non-accidental injury should beconveyed to the parents in a neutral and matter offact way. It is not in the interests of children orparents for child abuse to be covered up. To do soleaves the parents at greater risk ofinflicting moresevere injuries next time, being imprisoned forcausing more severe injuries, and losing longterm custody oftheir children. Early interventionmay help to prevent these events.

It is the duty of front line doctors to refer allchildren with suspected non-accidental injury.Failing to do so is a form of professionalnegligence. In the United States failing to reportsuspected child abuse is a federal offencepunishable by imprisonment.

Role ofthe consultant paediatricianIt is vital to the interests of the child, the

parents, and all the professionals concerned thatthe paediatrician reaches a correct and definitediagnosis in as many cases as possible. (This dutyshould not be delegated to junior staff.) If thepaediatrician sits on the fence he or she will notonly be in an uncomfortable position but also bedoing a disservice to the child and the parents. Ifthe paediatrician finds it impossible to decideinitially he or she should admit the child tohospital while investigations continue. Few casesare uncertain after a thorough multidisciplinaryinvestigation. The paediatrician shouldremember that he or she is being asked to commithimself or herself only on the balance ofprobabilities -not beyond all reasonable doubt.If the paediatrician genuinely cannot decidebetween non-accidental injury and an innocentinjury, he or she should return an open verdictand decisions should be guided by thepsychosocial assessment.

I thank the medical illustration units at the Royal VictoriaInfirmary and Newcastle General Hospital for their help,particularly Mr Peter Grenecis, medical photographer atDryburn Hospital.

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Assessed by front line doctor

Case 4: Finger tip bruisingThis 2 year old boy was admittedwith a fractured tibia, bruising tothe face, and classic finger tipbruising over the right scapula.

Case 5: Lash marksThis 10 year old girl was whippedwith a belt by her depressedfather. The linear nature of themarks is seen, together with atramlining effect, in which thepoint of impact is white and theadjoining skin shows bruisingcaused by capillaries that havebeen broken by blood beingforced into them.

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