The sexually abused battered child

A critical review of child abuse and its management in Africa

Introduction

Child abuse in Africa is a major threat to the achievement of the sustainable development goals on the continent and has become increasingly topical with a dramatic increase in recognition and an appreciation of the long term harmful effects on the affected population. The aim of this review was to outline current management of child abuse (especially sexual abuse) and highlight current preventive practice that could be beneficial in a resource-limited environment.

Methods

A search of Medline and reference lists of the literature on child abuse in African countries and relevant world literature was conducted in December 2016. The review was written narratively, rather than systematically as a general overview was desired, instead of a focused view of individual aspects of child abuse.

Recommendations

Opportunities for early identification of child abuse, as well as research into preventative strategies should be prioritised. Establishing strong institutions and guidance to tackle abuse when it occurs is both beneficial to the survivors and the continent at large.

Negligent and Inflicted Burns in Children

One in 4 American children have been abused and up to 5 children die per day from abuse. Children are vulnerable and error or lag in diagnosis may lead to further injury or death. In contrast, misdiagnosis of abuse is also unacceptable. Burns are a leading cause of abuse-related fatality and determination of cause can be difficult. It is critical that clinicians distinguish between burns of abuse (inflicted) and neglect and those received accidentally (noninflicted). Discordant narratives, use of alcohol and illicit substances, characteristics of the burn wound, and concomitant injury are all red flags for inflicted and negligent burns.

Are There Hallmarks of Child Abuse? II. Non-Osseous Injuries

Certain conditions have been considered hallmarks of child abuse. Such pathognomonic conditions have led to an inevitable diagnosis of inflicted injury. Forensic pathologists are faced with complex analyses and decisions related to what is and what is not child abuse. In this review, we examine the literature on the specificity of five conditions that have been linked to inflicted injury to varying degrees of certainty. The conditions examined include tears of the labial frena (frenula), cigarette burns, pulmonary hemorrhage and intraalveolar hemosiderin-laden macrophages as markers of upper airway obstruction, intraabdominal injuries, and anogenital injuries and postmortem changes. Analysis of the literature indicates that frena tears are not uniquely an inflicted injury. Cigarette burns are highly indicative of child abuse, though isolated cigarette burns may be accidental. Pulmonary hemorrhage is seen more commonly in cases with a history suggestive of upper airway obstruction, but is not diagnostic in an individual case. Hemosiderin-laden macrophages may be seen in cases with inflicted injuries and in natural deaths. Abdominal injuries may be seen in accidents and from resuscitation, though panreatico-duodenal complex injuries in children under five years of age are not reported to be seen in falls or resuscitation. The understanding of anogenital injuries is increasing, but misunderstanding of postmortem changes has led to miscarriages of justice.

The whole picture: Child maltreatment experiences of youths who were physically abused

The purpose of the current study was to describe the maltreatment experiences of a sample of urban youths identified as physically abused using the Maltreatment Case Record Abstraction Instrument (MCRAI). The sample (n=303) of 9-12 year old youths was recruited from active child protective services (CPS) cases in 2002-2005, and five years of child protective service records were reviewed. The demographic and maltreatment experiences of MCRAI-identified youths with physical abuse were compared to maltreated youths who were not physically abused and youths who were identified as physically abused by CPS when they entered this longitudinal study. T-tests and chi-square tests were used to compare the demographics and maltreatment experiences of the sample MCRAI-identified physically abused to the sample MCRAI-identified as nonphysically abused maltreated by gender. Of the total sample, 156 (51%) were identified by MCRAI as physically abused and 96.8% of these youth also experienced other types of maltreatment. Whereas youth with the initial CPS identification of physical abuse showed little co-occurrence (37.7%) with other forms of maltreatment. The MCRAI-identified physically abused youths had a significantly higher mean number of CPS reports and higher mean number of incidents of maltreatment than MCRAI-identified nonphysically maltreated youths. Lifeline plots of case record history from the time of first report to CPS to entry into the study found substantial individual variability in maltreatment experiences for both boys and girls. Thus, obtaining maltreatment information from a single report vastly underestimates the prevalence of physical abuse and the co-occurrence of other maltreatment types.

Anal signs of child sexual abuse: a case-control study

Background

There is uncertainty about the nature and specificity of physical signs following anal child sexual abuse. The study investigates the extent to which physical findings discriminate between children with and without a history of anal abuse.

Methods

Retrospective case note review in a paediatric forensic unit.

Cases: all eligible cases from1990 to 2007 alleging anal abuse.

Controls: all children examined anally from 1998 to 2007 with possible physical abuse or neglect with no identified concern regarding sexual abuse. Fisher’s exact test (two-tailed) was performed to ascertain the significance of differences for individual signs between cases and controls. To explore the potential role of confounding, logistic regression was used to produce odds ratios adjusted for age and gender.

Results

A total of 184 cases (105 boys, 79 girls), average age 98.5 months (range 26 to 179) were compared with 179 controls (94 boys, 85 girls) average age 83.7 months (range 35–193). Of the cases 136 (74%) had one or more signs described in anal abuse, compared to 29 (16%) controls. 79 (43%) cases and 2 (1.1%) controls had >1 sign. Reflex anal dilatation (RAD) and venous congestion were seen in 22% and 36% of cases but <1% of controls (likelihood ratios (LR) 40, 60 respectively), anal fissure in 14% cases and 1.1% controls (LR 13), anal laxity in 27% cases and 3% controls (LR 10).

Novel signs seen significantly more commonly in cases were anal fold changes, swelling and twitching. Erythema, swelling and fold changes were seen most commonly within 7 days of last reported contact; RAD, laxity, venous congestion, fissure and twitching were observed up to 6 months after the alleged assault.

Conclusions

Anal findings are more common in children alleging anal abuse than in those presenting with physical abuse or neglect with no concern about sexual abuse. Multiple signs are rare in controls and support disclosed anal abuse.

Diagnostic imaging of child abuse

The role of imaging in cases of child abuse is to identify the extent of physical injury when abuse is present and to elucidate all imaging findings that point to alternative diagnoses. Effective diagnostic imaging of child abuse rests on high-quality technology as well as a full appreciation of the clinical and pathologic alterations occurring in abused children. This statement is a revision of the previous policy published in 2000.

Childhood Abuse and Delinquency: A Descriptive Study of Institutionalized Female Youth in Singapore

Childhood abuse experiences appear prevalent in institutionalized children and youth, but research to date has been limited. Moreover, there is no published study that has examined the issue of childhood abuse and delinquency within institutionalized children and youth in Singapore. This study was cross-sectional in design with follow-up criminal record checks. Data were collected from multiple data sources including official records, structured clinical interviews, and self-report questionnaires on 79 adolescent female residential youth. Two thirds reported having experienced childhood abuse and a higher proportion reported having previously engaged in self-harming behaviours. Participants with multiple types of abuse reported being abused at a younger age, were more likely to be subjected to repeated physical abuse, to have overdosed on medication, and to have reported more health and sexual concerns and trauma symptomatology than those who reported either experiencing one or no previous types of abuse. Fourteen (18%) of the sample had been convicted of further criminal offences over a 6½-year follow-up. The adolescents with histories of multiple types of abuse in childhood presented with more health concerns and traumatic symptomatology, self-reported delinquency, as well as past self-harming behaviour during their institutional stay. Identification of these additionally vulnerable adolescents has important clinical implications for identification, assessment and intervention planning.

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries

INTRODUCTION

A torn labial frenum is widely regarded as pathognomonic of abuse.

METHODS

We systematically reviewed the evidence for this, and to define other intra-oral injuries found in physical abuse. Nine studies documented abusive torn labial frena in 27 children and 24 [corrected] were fatally abused: 22 were less than 5 years old. Only a direct blow to the face was substantiated as a mechanism of injury.

RESULTS

Two studies noted accidentally torn labial frena, both from intubation. Abusive intra-oral injuries were widely distributed to the lips, gums, tongue and palate and included fractures, intrusion and extraction of the dentition, bites and contusions.

CONCLUSIONS

Current literature does not support the diagnosis of abuse based on a torn labial frenum in isolation. The intra-oral hard and soft tissue should be examined in all suspected abuse cases, and a dental opinion sought where abnormalities are found.

Unique and combined contributions of multiple child abuse types and abuse severity to adult trauma symptomatology

Studies have documented the co-occurrence and cumulative impact of multiple types of child maltreatment on later psychosocial difficulties. Other research suggests that child abuse characteristics indicative of severity may also increase risk of later adjustment problems. However, little effort has been made to examine the co-occurrence of both multiple types of maltreatment and abuse severity within a single study. The present investigation examines self-reported child maltreatment and adult functioning in a geographically diverse sample of 1,396 undergraduate students. Results indicate that experiencing multiple types of maltreatment is positively associated with more severe abuse. Although increased maltreatment types and more severe abuse are each associated with greater trauma symptomatology, abuse severity is the stronger of the two predictors. Finally, number of maltreatment types and severity of maltreatment interact to predict greater levels of trauma symptomatology. These results highlight the importance of considering both co-occurring abuse types and severity in research and clinical work with adult victims.

Update on childhood sexual abuse

PURPOSE OF REVIEW

Childhood sexual abuse (CSA) is a problem of epidemic proportion affecting children and communities worldwide. This review will examine the most recent published CSA literature emphasizing not only new findings in diagnosis, management, and prevention, but also practice implications for the medical and community-based provider. Sexual assault and rape, though forms of sexual abuse, are broader than the scope of this article and not discussed in detail at this time.

RECENT FINDINGS

Prevalence rates for CSA are difficult to obtain. To identify populations at greatest risk and tailor treatment and prevention initiatives, consistent methods for defining and reporting cases of CSA are needed. Appreciating the quality and quantity of adverse health outcomes associated with CSA has helped clinicians and community providers expand and develop treatment programs. The physical and psychological late effects of abuse can be permanent and life threatening and the primary care provider should assess for mental health problems as well as physical maladies in all routine examinations. Children do not often disclose experiences of abuse for months to years and caregivers must be cognizant of the medical and behavioral indicators that signal early abuse. Child advocacy centers are community-based programs that incorporate medical, psychological, and legal support services for children and their families. This therapeutic model is based on a multidisciplinary team assessment aimed at decreasing stress, providing adequate protection and services for the child, and optimizing chances for a successful legal outcome.

SUMMARY

While prevention remains the ultimate goal, improved awareness and education for communities and professionals alike is required to ensure appropriate and quality care for all children who are sexually abused.

Skeletal injuries associated with sexual abuse

BACKGROUND

Sexual abuse is often associated with physical abuse, the most common injuries being bruising and other soft-tissue injuries, but fractures occur in 5% of sexually abused children. The fractures described to date have formed part of the spectrum of injuries in these children and have not been specifically related to the abusive act.

OBJECTIVE

To describe concurrent sexual abuse and fractures.

MATERIALS AND METHODS

Three children with pelvic or femoral shaft injuries in association with sexual abuse.

RESULTS

A 3-year-old girl with extensive soft-tissue injuries to the arms, legs and perineum also sustained fractures of both pubic rami and the sacral side of the right sacro-iliac joint. A 5-month-old girl with an introital tear was shown to have an undisplaced left femoral shaft fracture. A 5-year-old girl presented with an acute abdomen and pneumoperitoneum due to a ruptured rectum following sexual abuse. She had old healed fractures of both pubic rami with disruption of the symphysis pubis.

CONCLUSIONS

Although the finding of a perineal injury in a young child may be significant enough for the diagnosis of abuse, additional skeletal injuries revealed by radiography will assist in confirmation of that diagnosis and may be more common than hitherto suspected.

A preliminary study of a cartoon measure for children's reactions to chronic trauma

Preliminary psychometric properties of a new instrument, Angie/Andy Cartoon Trauma Scales (ACTS), are presented. Angie/Andy features a cartoon-based methodology, measuring trauma-related sequelae of prolonged, repeated abuse. A sample of 208 children comprised intrafamilial trauma, extrafamilial trauma, combined trauma, and nontrauma groups. Angie/Andy demonstrated high internal consistency, with coefficient alphas from 0.70 to 0.95. The three trauma groups scored significantly higher than the nontrauma group on all scales (p's < 0.0001). Generally, the most severely traumatized group scored significantly higher than the less severely traumatized groups. The number of types of violence exposures correlated with Angie/Andy scores from 0.55 to 0.74. The frequency and severity of trauma exposure correlated with Angie/Andy scores from 0.44 to 0.56. The Angie/Andy parent version correlated with a standardized parent scale from 0.71 to 0.81. Parent/child agreement was significant. Angie/Andy is a promising tool for clinical assessment of chronic childhood abuse.

Rape homicide involving children

Three rape homicide cases and two cases of attempted rape homicide involving children investigated in the Bonn University Institute of Forensic Medicine from 1992 to 1996 are described in order to assess whether characteristic features were present. The victims were girls aged from 3 to 12 years old. At autopsy haematomas, contusions and/or lacerations of the external/internal genitalia or anus confirmed sexual assault. Extragenital injuries found in every case included bruises, haematomas, abrasions and incised wounds caused by resisting, to struggling and manual pressure or gripping. Each death was caused by manual or ligature strangulation. The evidential value of the anogenital injuries encountered at autopsy is discussed and compared with the physical signs found at clinical examination.

Colposcopic genital findings in prepubertal girls assessed for sexual abuse

After the introduction of the colposcope for the examination of children suspected of being sexually abused in Leeds, a study was undertaken to describe the findings in detail. A total of 109 consecutive prepubertal girls, mean age 70.4 months were assessed including colposcopic genital and anal examination, and peer group review of reports and photographs. Fifty nine children had signs consistent with blunt force penetrating trauma (hymenal transection/major notch, scar, or hymenal attenuation). Transections were encountered most commonly at 6 o'clock (directly posterior). In 46 the hymenal orifice was gaping with thigh abduction only and in 47 the hymenal orifice transverse diameter was greater than 4 mm on labial separation. Overall, physical findings were commonly present and in only two cases were no signs recorded. Non-specific and frequent findings included patterns of labial and introital reddening. Supportive hymenal signs including swelling, rounding of edge, thickening, distortion, and loss of symmetry were common. Labial fusion was present in 20. Urethral dilatation with labial separation was noted in 14. Physical findings including normality are consistent with abuse and even minor anogenital signs as well as negative findings should be documented. Colposcopy and photography are valuable tools in peer review, teaching, and case management.

The worst combinations of child abuse and neglect

We have studied the impact of various kinds of abuse and neglect on the child's perception of himself and his future. We found, when considering physical abuse, physical neglect, verbal abuse, emotional neglect, and sexual abuse, that less than 5% of these mistreatments occurred in isolation. Since the vast majority of mistreated children are subject to more than one kind of abuse or neglect, it was important to delineate which combinations have the greatest effect. We found that a combination of physical neglect, physical abuse, and verbal abuse had the greatest impact on children, affecting such things as their enjoyment of living and hopes for the future. An early age of onset for verbal abuse and emotional neglect was significantly associated with greater severity and frequency of mistreatment. Neglect appears to be a precursor to abuse in many cases.