Signs of Physical Abuse
Signs of physical abuse can include injuries such as bruising and burning. Shaken Baby Syndrome and the lesser known Munchausen Syndrome by Proxy are two other injuries identified. Each of these listed abuse injuries is accompanied by what to look for in the way of injury patterns.
Depression and anxiety were two of the signs of physical abuse I displayed as a young child. As an older child, negative peer involvement began to surface. Then, as an adolescent, negative peer involvement escalated, and behaviour problems were at the top of the ‘signs’ list. According to a study of the signs of physical abuse done by Trocme, Nico & Wolfe (2001, p. 26 (1)): Physically abused children were generally reported as having considerable problems in child functioning. The five most often indicated concerns were:
- Behaviour problems (39%)
- Negative peer relations (15%)
- Depression or anxiety (15%)
- Violence to others (11%)
- Developmental delay (9%)
There are many types of child abuse and this section will focus on ten signs of physical abuse on children: (a) bruising, (b) beating, (c) burning, (d) choking / hanging, (e) smothering / drowning, (f) poisoning, (g) hair-pulling, (h) pushed from heights, (i) Shaken Baby Syndrome, and (j) Munchausen Syndrome.
Bruising in the most common of abuse injuries. There are four factors to take into account when determining whether or not the bruising is suspicious: location, size, colour and frequency.
- Upper thighs, especially inner thighs
- Trunk, buttocks
- Upper arms
- Sides of face, ears, neck
Normal bruising can be found on the knees, shins, elbows, and the forehead. Toddlers are especially vulnerable to forehead bruising, as they frequently bump into furniture, counters, anything that is at their head level. But the size of the bruise(s), the colour, and the frequency in which bruising occurs can turn even normal bruising into suspicious bruising.
Suspicious bruising can be found on the face, head, chest, back, arms, genitalia, thighs, back of the legs, and buttocks.
Pattern of bruises may be suggestive of abuse
- Multiple bruises in various stages of healing, especially on the trunk
- Any bruising in a non-ambulatory baby
- Hand prints or oval finger marks
- Belt marks – long broad band ending with horseshoe shape or puncture from buckle
- Loop pattern from cord, rope or wire that has been doubled up
- Petechiae (is a small 1-2mm red or purple spot on the body) or instrument pattern on buttocks from paddling, severe spanking
- Ligature pattern on neck, wrists, ankles
- Gag pattern on corners of the mouth
- Colour of bruises is not reliable for dating, but documentation of colors is important
The size of the bruise(s) can tell us what object or body part the child was struck and/or harmed with. See under Beatings and Choking for more details on size of bruising.
The colour of the bruise(s) can tell us how fresh the bruise is and the force with which the child was struck. With Caucasian people, a bruise takes on a red, purple, black or blue appearance when it first appears, depending on the force of the blow. As the bruise heals it will turn green, and then become jaundice yellow before fading away completely. Though it seems obvious, I’ll say it anyway: these changes in colour will be difficult to see in dark-skinned children. Just remember that bruising is only one sign; keep reading for other signs.
The more frequent the bruising incidents occur, the more likelihood of physical child abuse. The child may have a legitimate reason for the bruising, but if there are too many incidences, then the red flags of suspicion should go up.
The pattern of bruising and/or abrasions will resemble the shape of the object or body part used. The most common are belts, sticks, bats, bottles, and fists), but children are frequently attacked with firearms and knives.
If a belt is used, there will be red welts that are the width of the belt. There may also be bruising, and/or bleeding. The length of the welt depends on how much of the belt came in contact with the skin. Typically, caregivers who use a belt will strike the buttocks, the back, and the backs of the legs.
If a child is beaten with a fist, the shape of the bruise(s) can be that of a whole fist, or the bruising can show up as a cluster of lines (the imprint of the fingers of the fist). If the knuckles were used, bruising will be a line of roundish discolorations that are somewhere between the size of a dime and a quarter, depending on the size of the fist. Caregivers who use their fists generally give blows to the face, head, chest, stomach, and arms. Injuries are often to the face and head: black eyes, bloody and/or broken nose, fat and split lips, swelling of the eyes, cheeks or jaw, bruising and abrasions to the side of the head. Broken ribs and internal injuries can also result with severe blows to the chest and stomach.
Burning is the third most frequent cause of death in children from 1 – 14 years of age, and the fourth most frequent in children under one year of age (Feldman, 1987, p. 197(2)). 70 – 90% of childhood burns occur in the home during the winter months, early morning and late afternoons being the most vulnerable times (Feldman, 1987, p. 198(3)).
There are several kinds of burns: chemical, cigarette, electrical, heat, and water burns. Each present their own unique signs of physical abuse.
With chemical burns on the skin’s surface, depending on the chemical used, there can be a rash, blistering, and/or open sores that are pussing and/or bleeding. When caustic substances such as lye or acid are thrown, they are typically aimed at the child’s face. If a child is forced to ingest chemicals, there will likely be nausea, vomiting, cramping, chest and abdominal pain, distention, and possibly unconsciousness.
Cigarette burns will be the size and shape of the cigarette tip. Typically, caregivers who burn children/youth with cigarettes do so on the backs of the arms, the buttocks, and the backs of the legs.
Electrical burns appear as black marks at the site of the burn, and can extend beyond, depending on the electrical appliance used, and the volts of electricity the child is exposed to. Size and shape are also determined by these latter two factors.
Heat burns such as that from a flame and/or flammable liquid can encompass any part of the body. If clothing is ignited, the whole body can be burned. Victims of this type of burning are often older children.
It is important to note here that not all water burns constitute signs of physical abuse. Accidental water burns generally appear as a splatter of splash burns. With non-accidental water burns, excessive splash marks will appear above the site of the primary impact, on body parts where accidental burning is unlikely. A child who is held under flowing hot water or immersed in scalding water will learn that the pain is lessened if they keep perfectly still. What results is what the medical profession calls the red sock or red glove. There will be a clear margin of bright red skin starting where the water line was and continue to all parts of the body that were immersed. Typically, the buttocks, legs, feet, and hands. Eventually, there will be peeling of skin layers.
4. Choking and Hanging
With these signs of physical abuse, a child who is choked will have bruising around the front and back of the neck that will resemble the fingers and thumb of the caregiver doing the choking. The bruising can also take the shape of a red band, depending on the pressure used, the length of time the pressure was exerted, and how much of the hand came in contact with the skin. If the caregiver is facing the child, the bruises at the front of the neck will be two thumb imprints, while the bruising at the back of the neck will be a tier of finger marks. This will be reversed (finger marks at the front, thumb marks at the back of the neck) if the caregiver is behind the child when doing the choking.
Bruising and possibly ‘rope burns’ around the neck will be evident when a child ishanged. The bruising will take on the imprint of the rope or material used to hang the child.
With these two signs of physical abuse, the child may be hoarse and/or have a cough, especially immediately and shortly after the choking or hanging incident. Damage to the larynx can occur in more severe cases. In extreme incidences’, the neck may be broken.
5. Smothering and Drowning
During smothering, a child’s breathing may be compromised, but other than this immediate effect, there may not be any noticeable physical abuse evidence. There can be bruising around the face, especially the nose and eyes, and upper chest area, depending on the item used to do the smothering, and the force exerted to asphyxiate the child.
With drowning, there may be hand or finger bruising at the back or side of the neck, or at the shoulders where the child was held under water with force.
The child’s breathing may be jeopardized on a more long-term basis when these two signs of physical abuse are done regularly. If the child’s breathing is raspy or the child has difficulty catching his/her breath, this may be a sign of smothering or drowning.
Poisoning may be difficult to detect because quantity is what determines the ill effects.
Children can be poisoned with drugs, dish liquid, gas (i.e., combination of ammonia and bleach), and other noxious substances. A child who has been poisoned may suffer from nausea, vomiting, abdominal cramping, diarrhea, lethargy, sleepiness, light-headedness, dizziness, and, in more severe cases, unconsciousness. When noxious substances are force-fed to a child, depending on the substance, signs of physical abuse are: redness, chemical burns or bleeding in and around the mouth. If a child is forced to ingest dish liquid, the child will not be able to control his/her bowels, and a rash may be present around the mouth and lips.
Thinning hair and bald patches on the scalp may be present with severe hair-pulling. The child may experience headaches, and may also exhibit neck pain if the hair-pulling incidents are accompanied with jerking or snapping of the child’s head.
8. Pushed from Heights
Bruising and broken bones are the most common abuse injuries when a child ispushed from heights. If a child is pushed down a flight of stairs, bruising may be present anywhere and everywhere on the child’s body.
9. Shaken Baby Syndrome
Shaken Baby Syndrome (SBS) is the most common cause of infant mortality and accounts for the most long-term disability in infants and young children due to physical child abuse. It is frequently a single event and there may be no visible signs of injury.
The most common trigger for SBS is inconsolable crying. Feeding problems and difficulties with toilet training are also common triggers. Though there is often no intent to harm the child, the resulting injuries of SBS may be severe. Depending on the force used and the length of time the child is violently shaken, the signs of physical abuse are:
- Retinal damage in one or both eyes that may result in blindness
Shaken Baby Syndrome Statistics
70% of perpetrators are male and are often the father of the victim (Salazar, 2001, p. 66 (4)).
From 1997 to 2000, Shaken Baby Syndrome was the highest cause of death for infants killed by family members at 36% (Statistics Canada, 2002, p. 38 (5)).
Shaken Baby Syndrome is completely preventable, yet there are an estimated 50,000 cases each year in the United States (Ramirez, 1996, p. 2 (6)).
One in four shaken babies dies as a result of the abuse (Poissant & Linn, 1997, p. 33 (7)).
One-third of victims who develop symptoms escape without serious injury (Reece, 2002 (8)).
10. Munchausen Syndrome by Proxy
Munchausen Syndrome by Proxy (MSBP), also known as ficticious disorder, is defined as “the deliberate production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care, motivated by a psychological need to assume the sick role by proxy” (Barnett, Ola, et al., 1997, p. 44(9)). Generally, the victim is under the age of five, and the perpetrator of the physical child abuse is most often the child’s mother.
Perpetrators may use the following to cause the victims’ illness, resulting in a variety of signs of physical abuse:
- Administering laxatives, causing severe diarrhea and dehydration
- Applying substances to the skin that cause burns or rashes
- Altering lab test results
- Withholding required medication or over/under medicating
- Administering barbiturates, anti-depressants and/or poisonous substances
- Contaminating the child’s urine sample with blood, feces or other substances
Munchausen Syndrome by Proxy results in the child suffering from the caregiver’s actions. The child is at risk for long-term psychological problems, physical illnesses, as well as death. Health care professionals unknowingly become accomplices when they provide unnecessary and potentially dangerous testing procedures and therapies.
MSBP is very difficult to prove, in part, because this form of physical child abuse is so difficult to believe. Often, it is only suspected after a child is repeatedly admitted to hospital for treatment. The red flag for MSBP is when the child exhibits no symptoms or illness when the caregiver is away from the child for an extended period of time.
Perpetrators of MSBP may be motivated by the support, sympathy and attention they receive from health care workers. Family and friends are often supportive of what seems to be a very loving, concerned and caring mother anxious to get help for a sick child. Some perpetrators have considerable experience and/or knowledge in health related areas and may enjoy working with health care staff (Barnett, Ola, et al., 1997, p. 44 (10)).
Ten “Signs of Physical Abuse” – Footnotes:
(1) Trocme, N. & Wolfe, D. (2001). Child maltreatment in Canada: Canadian incidence study of reported child abuse and neglect: Selected results. Ottawa: National Clearinghouse on Family Violence, Health Canada.
(2) Feldman, K. (1987). Child abuse by burning. In R. Helfer & R. Kempe (Eds.), The Battered Child (197-293). Chicago: The University of Chicago Press.
(3) Child abuse by burning. In R. Helfer & R. Kempe (Eds.), The Battered Child (197-293). Chicago: The University of Chicago Press.
(4) Salazar, A. (2001). The second conference on Shaken Baby Syndrome syllabus. Saskatchewan Institute on Prevention of Handicaps: Government of Saskatchewan.
(5) Statistics Canada. (2002). Family violence in Canada: A statistical profile 2002. Catalogue no. 85-224-xie. Ottawa: Government of Canada.
(6) Ramirez, D. (1996, November). Beware of the dangers of shaking infants. Star Telegram (Fort Worth, Texas), B2.
(7) Poissaint, A. & Linn, S. (1997, spring/summer). Fragile: Handle with care. Newsweek: Special Issue.
(8) Reece, R. (2002). Shaken baby syndrome. Retrieved October 2002 from http:www.dontshake.com.
(9) Barnett, O., Miller, P., & Perrin, R. (1997). Family violence across the life span. Thousand Oaks, California: SAGE Publications, Inc.
(10) Barnett, O., Miller, P., & Perrin, R. (1997). Family violence across the life span. Thousand Oaks, California: SAGE Publications, Inc.