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PEDIATRICS Vol. 110 No. 3 September 2002, pp. 644-645

AMERICAN ACADEMY OF PEDIATRICS

When Inflicted Skin Injuries Constitute Child Abuse

	ABSTRACT

TOP ABSTRACT INTRODUCTION HISTORY RECENT TRENDS RECOMMENDATIONS Committee on Child Abuse... Liaisons Staff REFERENCES

 
Child abuse should be considered as the most likely explanation for inflicted skin injuries if they are nonaccidental and there is any injury beyond temporary reddening of the skin. Minor forms of abuse may lead to severe abuse unless abusive skin injuries are identified and labeled as such and interventions are made.

	INTRODUCTION

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Increasingly, there is apparent disagreement between the medical community and other professionals about when an inflicted injury causes enough concern to be considered abuse. Traditional medical definitions of physical abuse are being challenged by intervening social legislation, judicial decisions, and administrative policies. This disagreement may pose a problem for the pediatrician in deciding when to report injuries as child abuse. This statement addresses instances in which the pediatrician either knows or suspects that skin injuries are inflicted and nonaccidental.

	HISTORY

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For more than 5 decades, recognition of the problem of child physical abuse has been increasing.^1,2 This problem gained considerable impetus with the first reports of "battered child syndrome," in which children who suffered from repeated, severe trauma with patterns and histories that could be deciphered as occurring from inflicted abuse were identified. Many publications have since aided the pediatrician in determining patterns of specific abusive and nonabusive injuries and in deciding whether child abuse may be at least a reasonable suspicion, which is the criterion for initiating a child abuse report in most states.^4–6 The American Academy of Pediatrics has also contributed to the identification of child physical abuse through several publications^7–11 and many educational efforts.

Implicit in each of the many efforts to describe physical abuse has been a corresponding definitional assumption about what is and is not physical abuse. Certain trends emerge, including the following:

• The injury is not only inflicted but also nonaccidental (compared with, for example, a parent accidentally stepping on a child’s toes, causing bruising).
  
• The pattern of injuries fits a biomechanical model of trauma that is considered abusive (eg, handprint bruise on the face).
  
• The pattern of injuries may correspond to infliction with an instrument in a manner that would not occur through play or natural environmental interactions (eg, loop cord injuries).
  
• The history of injury provided is not in keeping with the child’s development (eg, a 1-month-old rolling off the bed).
  
• The history does not explain the injury (eg, bruising versus temporary red marks from spanking).
  

A definition of significant trauma is any injury beyond temporary redness of the skin. Although cellular injury may occur as a result of any trivial trauma, to be considered physical abuse, an injury must be overt enough to be recognized. Nonaccidental bruises, burns, punctures, lacerations, and abrasions are abuse, because tissue has been damaged, and the healing process occurs over time. One practical criterion often used is that any inflicted injury that lasts more than 24 hours constitutes significant injury (ie, physical abuse).¹²

It is helpful to have an experienced pediatrician working with suspected abuse cases to not only identify abuse when it occurs, but also prevent occasional situations in which an inexperienced person may misidentify an accidental injury as abuse. In some situations such as skin injuries from medical rituals (eg, coin rubbing), the question of what constitutes abuse requires careful consideration.⁶

Not all physical abuse is of equal severity nor does it warrant the same community intervention. With early identification of abuse, protective services may be provided to aid the child and family and avert future abuses. However, if minor forms of abuse are ignored, often this leads to reinjury and to more serious morbidity.^4–6 Until recently, there has been general agreement between the medical and legal communities about the definitions. Thus, physicians reporting physical abuse could usually expect child protective services to substantiate that injury occurred and enter the report on the state central child abuse registry (if other criteria were met).

	RECENT TRENDS

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Major shifts in social attitudes regarding which what acts constitute child abuse and what is acceptable physical discipline have led to a backlash. There have been efforts to deny the enormity of child abuse, once characterized as a "national epidemic."¹³ At times, physical discipline (and sometimes physical injury) of children has been justified by reference to religious belief.^14,15

Some states now place an act of child abuse on the central registry only when the abuse is considered "serious." The stigma of being labeled (even confidentially) as an abuser has evoked legislative sympathy in some states. Financial considerations and the legitimate fear of being overwhelmed by the number of abused children has led some child protective services systems to construct a triage system whereby a child has to be in relatively imminent danger or seriously abused before there will be a response. State supreme courts in Iowa and New Hampshire have ruled that bruising is not necessarily considered to be an injury.^16–18 Some states have laws that are ambiguous and at times are interpreted to appear to give license to physical injury in the course of punishment.^19,20 The result may be a tendency for some child protective services departments, which are already overloaded, to triage reports on the basis of severity of reported injury and delay or refuse to investigate less serious injury.

Any standard based on levels of injury is likely to be arbitrary and argumentative. It raises different standards for children than for adults. For example, a bruise on a child that might be considered "minor" and undeserving of much child protective services response might elicit a vigorous reaction if committed to an adult in a situation of intimate partner violence. Ultimately, children are demeaned by attitudes and policies that trivialize inflicted injuries and fail to label them for what they are—physical abuse.

	RECOMMENDATIONS

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1. Pediatricians must recognize that physical abuse consists of nonaccidental inflicted injuries.
   
2. Pediatricians should consider child abuse as the most likely explanation for inflicted skin injuries.
   
3. The Academy calls on state legislatures and Congress to avoid adoption of any laws or policies that create nonmedical definitions as to what constitutes nonaccidental inflicted skin injuries. Any existing laws and child protective services procedures that fail to conform to medical definitions of physical abuse should be repealed, and a clear statement should be made by state legislatures and Congress that protection of children is a state and national priority.
   
4. Pediatricians should work with legislatures and child protective services agencies at the state level to ensure implementation of this policy.
   
5. Pediatricians should counsel or provide appropriate referral to assist caregivers with appropriate behavior management of children.
   

	Committee on Child Abuse and Neglect, 2001–2002

TOP ABSTRACT INTRODUCTION HISTORY RECENT TRENDS RECOMMENDATIONS Committee on Child Abuse... Liaisons Staff REFERENCES

 
Steven W. Kairys, MD, MPH, Chairperson

Randell C. Alexander, MD, PhD

Robert W. Block, MD

V. Denise Everett, MD

Kent P. Hymel, MD

Carole Jenny, MD, MBA

John Stirling, Jr, MD

	Liaisons

TOP ABSTRACT INTRODUCTION HISTORY RECENT TRENDS RECOMMENDATIONS Committee on Child Abuse... Liaisons Staff REFERENCES

 
David L. Corwin, MD

American Academy of Child and Adolescent Psychiatry

Gene Ann Shelley, PhD

Centers for Disease Control and Prevention

	Staff

TOP ABSTRACT INTRODUCTION HISTORY RECENT TRENDS RECOMMENDATIONS Committee on Child Abuse... Liaisons Staff REFERENCES

 
Tammy Piazza Hurley

	REFERENCES

TOP ABSTRACT INTRODUCTION HISTORY RECENT TRENDS RECOMMENDATIONS Committee on Child Abuse... Liaisons Staff REFERENCES

 

1. Caffey J. Multiple fractures in long bones of infants suffering from chronic subdural hematoma. AJR Am J Roentgenol.1946; 56 :163 –173[Web of Science]
2. Silverman FN. Roentgen manifestations of unrecognized skeletal trauma in infants. AJR Am J Roentgenol.1953; 69 :413 –427[Web of Science]
3. Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA.1984; 251 :3288 –3294[Abstract/Free Full Text]
4. Helfer RE, Kempe RS. The Battered Child. 4th ed. Chicago, IL: The University of Chicago Press; 1987
5. Ludwig S, Kornberg AE. Child Abuse: A Medical Reference. 2nd ed. New York, NY: Churchill Livingstone; 1992
6. Reece RM. Child Abuse: Medical Diagnosis and Management. Philadelphia, PA: Lea & Febiger; 1994
7. American Academy of Pediatrics and the C. Henry Kempe National Center on Child Abuse and Neglect. The Visual Diagnosis of Child Physical Abuse [slide and study guide kit]. Elk Grove Village, IL: American Academy of Pediatrics; 1994
8. American Academy of Pediatrics, Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths. Pediatrics.1999; 104 :1158 –1160[Abstract/Free Full Text]
9. American Academy of Pediatrics, Committee on Child Abuse and Neglect and American Academy of Pediatric Dentistry, Ad Hoc Work Group on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics.1999; 104 :348 –350[Abstract/Free Full Text]
10. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Distinguishing sudden infant death syndrome from child abuse fatalities. Pediatrics.1994; 94 :124 –126[Abstract/Free Full Text]
11. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Shaken baby syndrome: inflicted cerebral trauma. Pediatrics.1993; 92 :872 –875[Abstract/Free Full Text]
12. Iowa Department of Human Services. Employees’ Manual. Des Moines, IA: Iowa Department of Human Services; 1997
13. The US Advisory Board on Child Abuse and Neglect. Child Abuse and Neglect: Critical First Steps in Response to a National Emergency. Washington, DC: US Department of Health and Human Services; 1990
14. Asser SM, Swan R. Child fatalities from religion-motivated medical neglect. Pediatrics.1998; 101 :625 –629[Abstract/Free Full Text]
15. American Academy of Pediatrics, Committee on Bioethics. Religious objections to medical care. Pediatrics.1997; 99 :287 –291
16. Tracey Hildreth v Iowa Department of Human Services, 550 NW2d 157 (Ia 1996)
17. In re Ethan H, 135 NH 681, 609 A2d 1222 (NH 1992)
18. Petition of Doe, 126 NH 719, 495 A2d 1293 (NH 1985)
19. Okla Stat ch 416, A3, 7106 (1998)
20. NC Gen Stat 7B-101

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