Physical Abuse (Non-Accidental Trauma)

Disease/ Disorder

Definition

Pediatric physical abuse (non-accidental trauma) is a form of child maltreatment caused by an act on the part of parent or caretaker that results in injury or physical damage to the child, which is not the result of an accidental incident.¹ Child maltreatment as a whole encompasses sexual abuse, neglect, negligence, physical abuse, and emotional abuse.²

Etiology

Physical abuse most commonly presents as injuries to skin and soft tissue; approximately one-third of non-accidental trauma results in fractures. Abusive head trauma is typically the most serious concern in children suffering from abuse, usually occurring during the first year of life with an estimated 25% to 30% mortality rate.²

Epidemiology including risk factors and primary prevention

Non-accidental trauma is the second leading cause of mortality in infants and children. In 2018, the US Department of Health and Human Resources identified 678,000 children as victims of child maltreatment with 10.7% being physically abused and 15% victims of two or more maltreatment types. An estimated 1,770 fatalities resulted from abuse or neglect, nearly half of which were younger than one year.² There is a 25% risk of serious injury and 5% risk of death in all cases of physical abuse. Mortality rates are more than doubled (25% vs 10%) in recurrent victims of non-accidental trauma.^3,4

Risk of suffering child maltreatment is inversely related to age, with the highest rates in children less than 1 year of age. The highest rates of child maltreatment are in girls and those of Native American or African American race or ethnicity. Premature birth and complex medical conditions are also associated with greater risk for suffering child maltreatment.²

Most perpetrators of child maltreatment are between the age of 18 and 44 (83.3%), female (53.8%), and a parent to their victim (77.5%). The three largest groups of perpetrators are White (49.6%), African American (20.6%), and Hispanic (19.3%). Parents who have substance abuse problems or were abused have a higher likelihood of becoming abusers. Abusive parents are more likely to be female, however male abusers are more likely to inflict trauma resulting in death. Familial dysfunction including a history of substance abuse, psychiatric disorder, or violent criminal record are identified in a family member in most cases of pediatric non-accidental trauma.^2,5

Patho-anatomy/physiology

Physical abuse injury at the cellular level and can affect the skin, musculoskeletal and neurological systems. The immature brain has an inherent difference in balance of neurotransmitters, blood flow, and energy requirements to support actively developing dendrites and synapses. There is increased excitotoxity and apoptosis that neurons use for neuroplasticity and development with abusive head trauma, this increases the vulnerability of young children to secondary injury through trauma-induced apoptosis and an enhanced neuroinflammatory response after injury. Trauma during this period may also alter axonal and dendritic growth. Additionally, children have disproportionately large heads with relatively weak necks predisposing them to cervical injuries which may cause injury to the brainstem through torque or stretch.⁶

Essentials of Assessment

History

An in-depth history including events leading up to presentation, symptoms, and prior injury in addition to standard past medical history, allergies, medications, and family history should be collected. This can be challenging as a child may be non-verbal or a caregiver may be unaware of events related to abuse, not forthcoming, or also a victim of abuse.^1,7  

Red flag history components are as below^4,7

• Inconsistencies or changes in the clinical history
• Pattern of injury inconsistent with the provided history
• Incompatibility of the injury and developmental abilities
• Delay in seeking medical care
• Poor parent-child interaction
• Different histories given by different caregivers
• Usage of multiple emergency departments
• Several failed routine appointments

Questions related to familial substance abuse, mental health problems, social/financial stressors, intimate partner violence, law enforcement involvement, and prior involvement with child protective services can be helpful in determining abuse risk status.^1,7

Physical examination

Anthropometric measures (height, weight, head circumference) may be a clue to concurrent child neglect. A thorough examination of the undressed child should be performed in additional to a neurologic exam including level of arousal, and fine and gross motor capabilities. Cutaneous findings such as bruises, burns, and lacerations are commonly present and easily identified.¹ Check for bruises in unusual locations including intraoral injuries, bruises of varying ages, and bruises in nonmobile children. There is an association with intraoral injuries and bruises in nonmobile children with future abuse. The presence of three or more of six characteristics (bruising, seizure, apnea, long bone fracture, retinal hemorrhage, or rib fractures) is highly predictive of abusive head trauma.⁷

Red flag physical exam components are as below:

Cutaneous signs and symptoms^4,7

• Bite marks
• Bruising in infants younger than 4 months
• Bruising over sites other than bony prominences, especially in non-ambulatory children
• Bruising of the torso, ears, neck, frenulum, angle of the jaw, cheek, eyelid, and subconjunctiva
• Patterned bruising (i.e., in the shape of a hand, belt buckle, or cord)
• Burns in a stocking-glove distribution sparing creases, palms, or soles (suggestive of immersion into scalding water)
• Burns in the shape of a distinctive object such as a cigarette

Musculoskeletal signs and symptoms^4,7

• Spiral fractures of the arm or leg (from being forcefully dragged or pulled)
• Posterior rib fractures (from being held by the chest and shaken)
• Sternal fractures (from being forcefully struck in the chest)
• Femur fracture prior to age of walking
• Humerus fracture in children under 3 years old
• Metaphyseal corner (bucket-handle) fractures (from traction of ligaments on bone attachment points)
• Fractures at multiple stages of healing, indicating multiple episodes of trauma

Neurological signs and symptoms^4,7

• Mental status changes (i.e., seizures, vomiting, poor feeding, and lethargy)
  • Are non-specific, but raise concern for abusive head trauma
• Retinal hemorrhages (from rapid acceleration and deceleration effects)
  • Are present in 60-85% of non-accidental trauma and severe retinal hemorrhages are almost always due to abuse

When possible, skin injuries should be measured and photo-documented.⁷ When available, a child abuse pediatrician should be involved as evaluation by a subspecialist reduces false-positive and false-negative evaluations.¹

Functional assessment

Observe the child’s behavior and how they interact with the parent, the providers, and other members of the family. Assess if there is an overly accommodating nature, a significant change in the patient’s abilities relative to baseline, or if there are elements of the child that are developmentally regressed from what would be expected for their chronologic age.

Laboratory studies

In children with bruising or intracranial hemorrhage, evaluation should include a complete blood count with platelet count, prothrombin time (PT), activated partial thromboplastin time, (aPTT) international normalized ratio (INR), and Factor VIII and IX levels. For bruising, a von Willebrand factor is additionally recommended. For intracranial hemorrhage, a fibrinogen and d-dimer should be included. Liver function tests, amylase, and lipase can be helpful in screening for occult intra-abdominal injury. With fractures, studies to evaluate bone health including calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and 25-hydroxy vitamin D should be included. For repeat fractures, genetic testing for osteogenesis imperfecta should be considered as well. With children presenting with altered mental status, toxicology testing should be performed, while its use in asymptomatic children is controversial.⁷

Imaging

A skeletal survey is recommended by multiple national pediatric and radiology specialty organizations in all children younger than 2 years when there are concerns for physical abuse and detect occult injuries in 11-34% of cases. In children older than 2 years old, a skeletal survey can be considered on a case-by-case basis with dedicated plain films helpful for areas of concern. Skeletal survey should be considered in any child unable to communicate areas of pain. Negative skeletal surveys may need to be repeated in 2-3 week to reveal missed fractures, identify additional injuries, or clarify prior injuries.⁷ Children with metabolic or other causes of osteopenia typically have signs of bone demineralization along with fractures on imaging.

Computed tomography (CT) of the head without contrast is preferred as the initial evaluation tool in all children with suspected intracranial injury because of the rapid availability, cost-effectiveness, sensitivity for skull fracture and acute intracranial hemorrhage, and ability to inform the need for urgent neurosurgical intervention. Magnetic resonance imaging (MRI) should also be considered and can further evaluate injuries, help identify chronic lesions and detect early ischemic injury.⁷ Children with intracranial lesions should also undergo a cervical spine MRI due to the higher detection rates of spinal cord damage compared to CT.⁸ Spinal cord injury without radiographic abnormality (SCIWORA) is often found with abusive head injuries and should be suspected in children with symptoms of myelopathy with negative CT findings.⁹ Ultrasound is not an appropriate imaging modality for evaluation of physical abuse.

Supplemental assessment tools

In abusive head trauma, children may present with apnea with hypoxemia, hypotension, seizures, and coinciding polytrauma with fractures and intraabdominal injury. If suspected, these should be investigated thoroughly with the appropriate laboratory and imaging studies.⁶

A dilated fundoscopic examination by an experienced pediatric ophthalmologist is recommended, ideally within the first 24-72 hours, to evaluate for ocular trauma including retinal hemorrhage in children with intracranial injury of if abusive head trauma is suspected.⁷

The TEN-4-FACES is a validated clinical decision tool with 87% specificity and 96% sensitivity for identifying non-accidental bruising in children less than 4 years old. The mnemonic stands for “T”orso, “E”ars, “N”eck, patients under “4” years of age, “F”renulum, “A”ngle of the jaw, “C”heek, “E”yelids, and “S”ubconjunctival region.¹

Impairment based measurement

Notation of the Glasgow Coma Scale or use of a trauma scoring index to assess severity of presentation is useful for future prognosis.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs) / changes in clinical practice behaviors and skills

Providers must be aware that there are many medical conditions that may mimic physical abuse including congenital dermal melanosis (Mongolian spots), hematomas as a result of coagulopathy (including hemophilia or von Willebrand disease), urticaria pigmentosa, bullous impetigo, phytophotodermatitis, laxative-induced dermatitis, Henoch-Schonlein purpura, osteopenia, metabolic bone disease, or osteogenesis imperfecta. These often present with bruising or fracture out of proportion to reported trauma.¹

Siblings or other household children and children cared for by the alleged perpetrator should be screened and evaluated for physical abuse.⁷

Misdiagnosis of physical abuse can result in unnecessary removal of a child from the family, alter the family dynamics, and have a heavy psychological toll on all involved. Conversely, when not identified, it can contribute to lifelong physical impairment, developmental delay, mental health disorders, and even death.¹

Early predictions of outcomes

In abusive head trauma, early hypoxemia and hypotension, age less than 2, and severity of injury (SDH or GCS <8) are strong predictors or seizures and are linked with poor outcome due to increased excitotoxicity.⁶ Negative outcomes after non-accidental trauma are more often seen in children with severe initial injuries, injuries affecting the central nervous system, and younger ages. An estimated 50% of children who are victims of non-accidental head injury will have some degree of permanent cognitive and behavioral deficits.¹⁰Along with cognitive and behavioral effects, impairments are often observed in the form of motor development (spastic quadriplegia/diplegia 15-64%), epilepsy (11-32%), cortico-subcortical atrophy (61-100%), visual impairment (18-48%), and language disorders (37-64%).Worse outcomes in non-traumatic head injury patients are more likely in children presenting with coma, seizures, associated cranial fracture, evidence of cerebral atrophy.¹¹Late neurologic and cognitive sequelae have been found to correlate with Pediatric Trauma Score and Glasgow Coma score, but not with age or with mechanism of injury.¹²

Factors predicting positive functional outcomes are isolated musculoskeletal or limited dermatologic findings. However, emotional outcomes are not easily predicted by the severity of physical findings. Children who are relatively physically intact can still have lasting deficits from abuse that negatively impacts emotional, social, and cognitive development.

Environmental

Nonaccidental trauma can happen to persons of any race, religion, ethnicity or socioeconomic status. The bias the examiner may have of the presenting victim and their family may affect the likelihood that nonaccidental trauma is recognized.

Social role and social support system

The involvement of child life specialists, social work, and physician specialists equipped to further evaluate and support victims is critical. These personnel, or the initial reporter, should involve law enforcement authorities when information supporting the suspicion of nonaccidental trauma is accrued.

When communicating to families the involvement of child protective services, providers should first ensure the safety of the child and discuss concerns for maltreatment privately with the caregiver. This should be done in an open, honest, direct, and non-judgmental manner.⁷

Child protective services agencies (CPS) conduct an independent investigation of suspected child abuse or neglect to determine if it meets the individual state definition of abuse or neglect. They assume responsibility for the protection of the child and determine whether a child is to remain in the home with services to support and help families or if removal and placement in kinship or foster care is appropriate. Law enforcement may be involved to help determine if a crime was committed and who is responsible for committing the crime.⁷

Professional issues

Physicians are mandated reporters of child maltreatment in all states as defined by the Child Abuse Prevention and Treatment Act (CAPTA). This requires the reporting of any reasonable suspicious for child abuse or neglect for further investigation; certainty of abuse is not required. Reporting systems and mandated reporting laws may vary by state. All states have some level of immunity for reporting in good faith reasonable suspicion of child maltreatment. Failure to report can lead to criminal charges, implications on medical licensing and malpractice, and continued risk to the child.⁷

In the medical and legal setting, physicians who care for children have a responsibility to understand that evaluation and diagnosis of physical abuse should be based on sound data or research methodology and not alternative theories. In recent years, unsupported theories of alternative causes of symptomology including Ehlers-Danlos Type III to explain fractures in infants, infant vitamin D deficiency as a cause of subdural hemorrhage, and dysphagic choking as a cause of infant death.⁷

Rehabilitation Management and Treatments

Available or current treatment guidelines

Physical medicine and rehabilitation should be involved in cases of physical abuse beginning in the acute stage. Based on impairments, children with central nervous system or musculoskeletal injuries may benefit from inpatient or outpatient therapy services. This may include acute inpatient rehabilitation in those with more moderate to severe impairments, outpatient or home health therapy services, and neuropsychological evaluation as appropriate. Children that are victims of head trauma, both abusive and non-abusive in nature, show significant functional and expressive language improvements with acute inpatient rehabilitation.¹³ However, unfortunately a large number of children who would benefit from rehabilitation services do not receive them.^14,15 All children who are victims of abuse should be evaluated for and receive ongoing psychiatric and psychosocial support as appropriate.

Coordination of care

• Parallel practice: Individual practitioners should involve a team of professionals to address the medical, social, legal, and emotional issues related to nonaccidental trauma. It is contrary to best practice to do all aspects of care in isolation.
• Coordinated: Efforts between the medical staff, the psychosocial support team, and the law enforcement and government agencies is essential for treating the child and maintaining them in a safe environment.
• Integrated: Documentation is critical to the process. When directly quoting information from the victim and/or the perpetrator, quotation marks should be used. Legible and careful notation is important. Drawings, sketches, and descriptions of the physical findings are encouraged. Police and governmental agencies use medical records to follow up on the incident of abuse.⁷

Patient & family education

The involvement of the family in the treatment and education process is ultimately determined by the circumstances around the abuse. Many advocacy groups have organized campaigns to promote awareness. However, most are geared towards the public as opposed to medical professionals.

Follow-up and long-term management

There is a high risk of severe disability and chronic health issues including developmental delay, physical disability, feeding difficulty, and psychological trauma.¹⁴ Given this risk, long-term comprehensive care should be coordinated to monitor development and implement appropriate interventions. Recommended intervention measures may range from education, psychosocial support, and family counseling. Fostering a supportive family environment is important, as studies suggest that deleterious traumatic brain injury effects are buffered by a positive family unit and exacerbated by negative family units.¹⁶

Children with non-accidental head trauma are likely to require and benefit from special intervention services. Available services include mental health, speech language pathology, rehabilitation, and special education. Special education services are provided through an Individual Education Plan (IEP) program, which outlines an individualized plan for children with more severe cognitive and behavioral disabilities, or the 504 plan, which provides extra accommodations in the classroom for children not requiring a full IEP.¹⁷

Consistent follow up of children who have suffered from physical abuse is challenging due to higher rates of being uninsured or underinsured, often undergoing multiple changes in guardianship, guardians who lack transportation or the ability to miss work, and having multiple subspeciality services requiring multiple routine visits.¹⁴

The lifetime cost of medical care for a survivor of abusive head trauma is estimated to be $2.6 million.¹ Of those who survive, up to 40% will have severe disability and require full assistance with activities of daily living.⁶ Functional impairment after abusive head trauma may become more evident as time goes on and developmental milestones are not met, and have residual impairments for years after injury. Deficits in attention, memory, and behavior often are recognized as a late sequelae as cognitive demands developmentally increase.¹⁴

Cutting Edge/ Emerging and Unique Concepts and Practice

Evolving and increasingly sophisticated imaging techniques are expected to provide a tool for improved detection of non-accidental trauma and may lead to better prediction of outcomes. 

There is ongoing refinement and implementation of prevention and detection strategies of physical abuse for the community and medical professionals from the American Academy of Pediatrics and its Council on Child Abuse and Neglect.

Gaps in the Evidence-Based Knowledge

Long-term outcomes remain highly variable among individuals with non-accidental head injuries.^2,17 More evidence is still needed to help with predicting and improving outcomes in this population.

There remains a lack of standardized interventions for abusive head trauma exacerbated by lack of inclusion in larger, multi-center studies on traumatic brain injury.

References

1. Ngo V. A Closer Look: Medical Conditions that Mimic Physical Abuse. Pediatr Ann. 2020;49(8):e341-e346.
2. Department of Health & Human Services AfCaF, Administration on Children, Youth, and Families, Children’s Bureau. Child Maltreatment 2018. https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment. 2020.
3. Deans KJ, Thackeray J, Groner JI, et al. Risk factors for recurrent injuries in victims of suspected non-accidental trauma: a retrospective cohort study. BMC Pediatr. 2014;14:217.
4. Weber L. Practical Guidelines for Identifying Non-Accidental Trauma in Children. Gillette Partners in Care Journal: Gillette Children’s Specialty Healthcare 2015.
5. Vinchon M, Defoort-Dhellemmes S, Desurmont M, et al. Accidental and nonaccidental head injuries in infants: a prospective study. J Neurosurg. 2005;102(4 Suppl):380-384.
6. Iqbal O’Meara AM, Sequeira J, Miller Ferguson N. Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature. Front Neurol. 2020;11:118.
7. Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatr Radiol. 2021;51(6):853-860.
8. Baerg J, Thirumoorthi A, Hazboun R, et al. Cervical spine injuries in young children: pattern and outcomes in accidental versus inflicted trauma. J Surg Res. 2017;219:366-373.
9. Szwedowski D, Walecki J. Spinal Cord Injury without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Pol J Radiol. 2014;79:461-464.
10. Duhaime AC, Christian C, Moss E, et al. Long-term outcome in infants with the shaking-impact syndrome. Pediatr Neurosurg. 1996;24(6):292-298.
11. Chevignard M, Camara-Costa H, Dellatolas G. Pediatric traumatic brain injury and abusive head trauma. Handb Clin Neurol. 2020;173:451-484.
12. Barlow KM, Thomson E, Johnson D, et al. Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. Pediatrics. 2005;116(2):e174-185.
13. Risen SR, Suskauer SJ, Dematt EJ, et al. Functional outcomes in children with abusive head trauma receiving inpatient rehabilitation compared with children with nonabusive head trauma. J Pediatr. 2014;164(3):613-619 e611-612.
14. Johnson BL, Gerzina EA, Naik-Mathuria B, et al. What happens after the hospital? An analysis of longitudinal care needs in children treated for child physical abuse. J Pediatr Surg. 2021;56(10):1696-1700.
15. Jensen AR, Evans LL, Meert KL, et al. Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism. Child Abuse Negl. 2021;122:105333.
16. Yeates KO, Taylor HG, Walz NC, et al. The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children. Neuropsychology. 2010;24(3):345-356.
17. Forsyth R, Kirkham F. Predicting outcome after childhood brain injury. CMAJ. 2012;184(11):1257-1264.

Original Version of the Topic:

Maurice Sholas, MD, PhD. Physical Abuse (Nonaccidental Trauma). 10/11/2011.

Previous Revision(s) of the Topic

Maurice Sholas, MD, PhD. Physical Abuse (Nonaccidental Trauma). 8/16/2016

Heakyung Kim, MD, Matthew Erby, MD. Physical Abuse (Nonaccidental Trauma). 8/3/2020

Author Disclosure

Heakyung Kim, MD
Nothing to Disclose

Kayla Williams, MD
Nothing to Disclose