Continuing Medical Education
Cutaneous signs of child abuse

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Maltreatment of children is a major public health crisis, and it is estimated that each year more than 3 million children are victims of abuse. Safeguarding the welfare of children is a priority, and it is the moral and ethical responsibility of healthcare professionals to detect cases of abuse and intervene appropriately to prevent further harm. Clinicians are often challenged to differentiate signs of child abuse from skin conditions that mimic maltreatment. Because cutaneous injury represents the most recognizable and common form of abuse, dermatologists are often called upon to help distinguish signs of intentional injury from skin conditions that mimic maltreatment. However, few resources specific to dermatologic signs of abuse exist to aid in diagnosis. A review of the literature will provide an educational resource to assist dermatologists and other clinicians in differentiating cutaneous signs of child abuse, including physical and sexual abuse, from mimickers of inflicted injury.

Learning objective

After completing this learning activity, participants should be able to distinguish signs of intentional injury from skin conditions that mimic maltreatment and understand the clinician's role in the diagnosis and reporting of cases of suspected child abuse.

Section snippets

Epidemiology

Widespread medical interest in abuse was initiated by the introduction of the term “battered child syndrome” in 1962. Since then, recognition of the problem of child physical abuse has been increasing. Child abuse is defined by the Child Abuse Prevention and Treatment Act (CAPTA), originally enacted in 1974, as any recent act or failure to act by a caretaker resulting in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm to a child.5

A

History

The keys to detection of child abuse involve identifying a combination of historical inconsistencies, suspicious findings on physical examination, and social risk factors.13 A comprehensive history, including medical history, trauma, and injury, is absolutely critical in determining the nature of cutaneous lesions.11 If the child is verbal and the injuries are suspicious of child abuse, it is important to speak with the child away from the caregivers. Simple and age-appropriate language should

Physical abuse

Physical abuse is one of the most common forms of child maltreatment, with traumatic skin lesions being the leading sign of abuse witnessed by physicians. The American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect has delineated certain features of skin injuries that are suggestive of child abuse. One criterion often used to identify physical abuse is “any inflicted injury that lasts more than 24 hours constituting significant injury.”7 An injury can be considered physical

Sexual abuse

In addition to physical abuse, childhood sexual abuse is a problem of epidemic proportions affecting children of all ages and economic and cultural backgrounds.65 More than 88,000 children were confirmed victims of sexual abuse in the United States in 2002.66 Studies have suggested that approximately 1% of children experience some form of sexual abuse each year, resulting in the victimization of 12% to 25% of girls and 8% to 10% of boys by 18 years of age.67 Of the 3 million cases of child

History

The physical examination holds an important place in the evaluation, but it is the history that sets the gold standard in cases of sexual molestation. Sexually abused children often present to medical personnel with a variety of symptoms, even though they have not disclosed maltreatment. The presenting complaints may be nonspecific, such as sleep disturbances, abdominal pain, enuresis, encopresis, or phobias.67 Some behaviors are also suggestive—but not diagnostic—of abuse. Studies have found

Psychological impact

The physical scars may heal, but the emotional and psychological sequelae of child abuse may endure and be more devastating. It is well known that the skin is a commonly used site for self-inflicted trauma in both children and adults with psychological problems.4 Many of the behavioral disorders seen today are often the result of childhood maltreatment. Such psychological trauma may actually be manifested by self-injurious sucking, biting, or scratching, which have recognizable cutaneous

Conclusion

An estimated 3 million “reported” cases of child abuse occur each year, yet the public outcry is significantly less than warranted. Because physical maltreatment overwhelmingly involves multiple regions of the skin, the dermatologist is at the forefront of substantiating whether or not abuse has occurred. Recognizing the cutaneous manifestations of child abuse may be challenging, but it is critical in making a correct diagnosis. Errors of omission can cost the life of a child, whereas errors of

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    Funding sources: None.

    Conflicts of interest: None declared.

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    Copyright © 2007 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.