PHYSICAL ABUSE

• Jurisdiction: Australia

Introduction ................................................................................................... [41C.200]

The types and patterns of injury in child abuse ........................................... [41C.220]

Medical investigations in child physical abuse ............................................. [41C.240]

Weighing up the evidence ............................................................................ [41C.260]

Medical conclusions in child physical abuse ................................................ [41C.280]

Pitfalls and realities in child physical abuse ................................................. [41C.300]

[41C.200] Introduction

Child physical abuse occurs when a child's body is physically harmed as a result of a caregiver's actions. These behaviours may involve striking, slapping, shaking, cutting, biting, burning, poisoning and suffocation. The effects on the child range from little or no obvious injury to death. Many instances of physical abuse involve short-term, impulsive violent carer behaviour. Other physical abuse patterns include multiple events of violence, some or all of which may be pre-meditated..

The observed injuries in children may provide clues as to how the injuries were caused. Most manifestations of physical abuse are seen in the skin and surface structures, including the eyes, ears and hair: Jenny and Reece (2009). Less apparent to the casual observer may be injuries to internal organs, bones, ligaments and the brain. Injuries to internal structures in a child's body may only be detected following medical investigation, which is one of the reasons why suitably trained medical professionals should be involved, from the outset, in the evaluation of suspected child abuse.

The term "non-accidental injury" is a broader term than "physical child abuse", although many authors refer to them synonymously. The term "non-accidental injury" refers to injury caused by anything other than an accident. An accident is perceived to be an unpredictable and unavoidable event. A non-accidental injury is, in broad terms, a physical injury sustained as a result of assault but it also includes physical injury sustained as a result of a caregiver's failure to act to protect a child from foreseeable harm. Bruising to a child's buttocks as a result of spanking is clearly an example of physical child abuse and non-accidental injury. The act of spanking of such severity that it causes bruising is behaviour that constitutes physical child abuse. Grey areas also exist between accidental and non-accidental injuries. For example, if a child is physically injured during an episode of interpersonal violence because the child intervened between the combative couple, many people would regard the child's injuries to have been caused non-accidentally.

To blur definitional boundaries even further, many professionals would consider actions by a caregiver that have the potential to cause physical injury to a child to fall within the definition of child physical abuse. An example of this situation occurs when a parent violently shakes an infant but the infant has no observable physical injury.

The range and severity of injuries amongst physically abused children are well described in standard paediatric, forensic and pathology textbooks: Jenny (2011); Busittil and Keeling (2009); Byard (2010). Research continues to increase knowledge about features that help to discriminate between accidental and non-accidental causes of some types of wounds and internal injuries. For example, better understanding of the biomechanics of children's posterior rib fractures has enabled the diagnosis of child abuse based on this finding to be made with greater (but not absolute) certainty. In contrast, detailed information about accidental causes of injury and medical conditions that might be confused with abuse has lessened diagnostic certainty about some forms of intracranial haemorrhage and occular trauma; findings that previously were held to be "almost pathognomonic" (ie, characteristic or indicative) of shaking. Significant controversies currently exist in relation to determining the possible causes of cerebral oedema associated with intracranial trauma and the cascade of physiological and chemical processes that are an integral part of the brain's response to injury and/or hypoxia. Research continues to improve our understanding of the biomechanics of injury to the infant brain. Infants' brains differ significantly from adults' brains in composition and response to trauma. Efforts are being made to design more biofidelic anthropomorphic models upon which to experiment: Margulies and Coats (2011).

In general terms, forensic evaluation of injury is a process that pivots around questions about forces, causal mechanisms, timing and circumstances surrounding injuries.

[41C.220] The types and patterns of injury in child abuse

Doctors who examine children in circumstances of suspected physical abuse must search for injuries that might initially be difficult to detect. These doctors are tasked with determining, if possible, the cause(s) of injuries, a task often referred to as "injury interpretation". Injury interpretation is an important aspect of clinical forensic medicine across the entire age spectrum and is particularly important when dealing with possible child abuse. The following list of injuries, their locations and some of their characteristics describes some, but certainly not all, of the injuries caused by physical abuse.

1. Bruises. Concerns about physical abuse arise when bruises are observed: Maguire (2010):

(a) in an infant or non-cruising young child;
(b) over an extensive area of the body, particularly when multiple planes of the body are affected;
(c) over soft tissues of the body, away from bony prominences;
(d) over ears, face, abdomen, genito-anal region, arms, back, buttocks and hands. These sites are infrequently injured as a result of common childhood accidents, playground or sporting activities; and
(e) in a recognisable pattern that suggests assault: multiple bruises in clusters might suggest pressure from finger tips, multiple bruises of similar shapes might suggest forceful contact with the same object, bruises (or a negative outline of bruises) surrounding the shape of a hand or recognised object such as a wooden spoon, tram-track patterned bruises suggest forceful contact with a linear object or edge, looped tram-track patterned bruises suggest contact with a flexible linear object such as looped flex, opposing arc shaped bruises suggest a human bite and circumferential bruises around limbs might generate concern about ligatures.

2. Lacerations and abrasions. In general, it is rarely possible to discriminate accidental from non-accidental injury on the basis of the appearance of a laceration or an abrasion. Suspicion about a non-accidental cause might arise when such wounds are:

(a) away from bony prominences, in relatively protected parts of the body such as inside the mouth or genitals;
(b) in a pattern suggestive of forceful contact with an object, for example, belt buckle, or ligature, for example, a rope;
(c) in a pattern that suggests a bite; and
(d) in a pattern suggesting multiple scratch abrasions from finger nails.

3. Burns and scalds. Immersion scalds, hot liquid scalds, contact burns and flame burns are more prevalent in children than adults. When compared to unintentional burns, abusive burns tend to be larger, involve younger children, be deeper and more often require grafting, have higher risk of mortality and longer hospital stays: Zolotor (2011). Occasionally the pattern of thermal injury can discriminate between an accidental cause and child abuse: Maguire (2008). A high index of suspicion about a non-accidental cause might arise when:

(a) the scald pattern in an infant suggests immersion of the child's lower limbs and trunk;
(b) the site suggests immersion of an entire

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