Diagnostic Challenges and Controversies in Child Abuse
Vincent J. Palusci, MD MS
Large numbers of children are abused and neglect each year around the world, and much of this maltreatment occurs out of sight, in families behind closed doors. When medical care is sought, physicians and other health professionals often have incomplete or purposely inaccurate information on which to act. While many children have few or no visible injuries after maltreatment, those who do can present diagnostic challenges and controversies as physicians must rely on physical examination findings, laboratory tests and imaging studies to figure out what happened.
Child abuse can cause predictable patterns of intentional injuries, but many of these can overlap with findings caused in accidents or by medical conditions unrelated to maltreatment. Bruises can point to the site and the source when a child is struck with an object. Burns can show immersion in scalding water or contact with flames or objects. Broken bones can show where the body has been bent, twisted, squeezed or shaken. Organs in the abdomen can show the impact of kicks or punches, and the genitals can show the tears from penetration or stretching.
Yet all of these injuries need to be assessed in the context of normal childhood development, parental supervision, overall physical and nutritional health, and the rare presence of underlying, predisposing disease. Does this bruise represent an intentional injury, a disorder of bleeding, or both? Did that fracture occur with a normal childhood fall, from an abusive twisting of the extremity, from an underlying weakness of the bone caused by deficiency or disease, or from all of these? Is this child emaciated because of disease or because the child was not being fed properly? Are those anogenital findings caused by trauma, normal variants at birth, the result of infections, or of unknown significance? And when did this likely occur? In the absence of eyewitnesses (including the child herself), the physician and the legal and protective systems often face uncertainty in determining what actually occurred, who was responsible, and what steps should be taken to prevent this from occurring again while simultaneously protecting the family’s right to remain together and the child’s right to grow up in a nurturing environment.
To this end, forensic pathologists and pediatricians have made great strides in expanding our knowledge about the medical assessment and diagnosis of child abuse and neglect. From publications in the 1960’s identifying physical abuse and battered child syndrome, through the 1970’s with Shaken baby Syndrome, and the 1980’s with sexual abuse and other maltreatment, there are now increasing numbers of studies detailing the epidemiologic and physiologic features of maltreatment’s mental and physical injuries. Current practice includes considering the consistency of any injuries identified with the intentional abusive act being considered, as well as considering the role of neglect, the contribution of underlying disease or deficiency, and the potential forensic issues involved in the diagnosis of child abuse and neglect. Lawyers and other professionals interested in the welfare of children need to learn what physicians know in the specialties of forensic pathology and the newly-certified field of child abuse pediatrics: we must use the best evidence available if we are to address the diagnostic challenges and controversies to protect children and families with suspected child abuse and neglect.
