Recognizing Signs of Potential Child Abuse

The following information about child abuse was taken from several sources. It is intended for Texas EMS professionals or others who are required by Texas Family Code to report abuse. Remember, when in doubt, let the experts at the Child Abuse Hotline make the determination. And always document all the information about a call.

If you suspect abuse, call Texas Child
 Protective Services at (800) 252-5400.

Questions to ask in identifying indicators of abuse 

• Are bruises symmetrical or are they found on only one surface (plane) of the body?
• Are bruises extensive—do they cover a large area of the body? 
• Are there bruises of different ages—did various injuries occur at different times? 
• Are there patterns caused by a particular object  (e.g., a belt buckle, a wire, a straight edge, coat hanger, etc.?) 
• Are injuries inconsistent with the explanation offered? 
• Are injuries inconsistent with the child’s age? 
• Are the patterns of the burns consistent with forced immersion in a hot liquid (e.g., is there is district boundary line where the burn stops—a “stocking burn”, for example, or a “doughnut”     pattern caused by forcibly holding a child’s buttocks down in a tub of hot liquid)? 
• Are the patterns consistent with a spattering by hot liquids? 
• Are the patterns of the burn consistent with the explanation offered? (Are they able to walk or crawl "into" their injuries?)
• Are there distinct patterns caused by a particular kind of object (e.g., and electric iron, the grate of an electric heater, etc.) or instrument (e.g., circular cigarette burns, etc.)?  

Risk factors for child mistreatment

• Isolated Families
• Parents overwhelmed with caregiving responsibilities
• Low tolerance for stress
• Low socio-economic status
• Emotionally immature parents – put adult needs first
• Alcohol and other drug abusw
• Single parents who make poor choices in partners
• Violent tendencies
• Poor understanding of child development
• Unrealistic expectations of child’s behavior
• Physical force as a form of discipline
• Child related factors
  • Young child at greater risk
  • Poor bonding
  • Difficult child
  • Medically/physically impaired child

Who abuses and neglects children?

• Both men and women abuse children  
• Occurs in all social, cultural and economic classes 
• Most often, the abuser is a parent, guardian, household or family member, or one with regular access to the child  
• Parents may have been abused as children  
• Have limited parenting skills
• May be under stress; i.e. unemployment, divorce, financial problems, poverty, family and life crisis 
• Parents with unfulfilled needs for nurturance and dependence  
• Parents with a severe lack of self-esteem or sense of self-worth  
• Are isolated with few or no outside sources for support  
• Have a “special child” – one who is mentally, physically or developmentally disabled  
• Are substance abusers

Behavior

The following behaviors may result from child abuse, although none are definite signs of abuse:

• Child is excessively passive, overly compliant, apathetic, withdrawn or fearful, or at the other extreme, excessively aggressive, destructive or physically violent
• Child and/or parent or caretaker attempts to hide injuries; child wears excessive layers of clothing, especially in hot weather; child is frequently absent from school or physical education classes
• Child is frightened of parents/caretakers, or at the other extreme, is overprotective of parents/caretakers
• Child is frightened of going home
• Child is clingy and forms inappropriate attachments
• Child is apprehensive when other children cry
• Child is wary of physical contact with adults
• Child exhibits drastic behavior changes in and out of parental/caretaker presence
• Child is hypervigilant
• Child suffers from seizures or vomiting
• Adolescent exhibits depression, self-mutilation, suicide attempts, substance abuse, or sleep and eating disorders
• Child lacks social boundaries (may hug a stranger, sit on a lap)

Environmental Factors

• Injuries incompatible with history given   
• Alcohol/drug use in household 
• Recent family stresses 
• Caregiver not seeking medical attention 
• Apparent unrealistic expectations of infant 
• History of diapering / toilet training difficulties 
• Caregiver at the time of injury was a male

Physical Signs / Symptoms

• Lethargy / decreased muscle tone   
• Difficulty breathing 
• Extreme irritability 
• Seizures 
• Decreased appetite or vomiting for no apparent reason
• Bruises on shoulders, neck or arms 
• Bulging or spongy forehead 
• No smiling or vocalization 
• Poor sucking or swallowing 
• Rigidity 
• Inability to lift head 
• Inability of eyes to focus or track movement 
• Unequal size of pupils

Shaken Baby Syndrome Fact Sheet

• Shaken baby syndrome is a form of abusive head trauma and accounts for an estimated 10-12 percent of all deaths resulting from abuse and neglect.  Approximately 25 percent of all SBS victims die and 41 percent are under age one. 
• The number one reason a baby is shaken is inconsolable crying.
• Shaking a baby causes the head to whip back and forth due to their large, heavy heads.  Such whiplash causes the brain to rotate wildly about the skull and blood vessels connecting the brain to the skull to tear.  Consequences include brain damage, seizures, paralysis, blindness and even death.
• As many as 25 to 50 percent of the American public does not know that shaking an infant can cause damage or death. 
• According to a national survey of child fatality review committees conducted by the National Information, Support and Referral Service on Shaken Baby Syndrome in 1998, 70 percent of the perpetrators of shaken baby syndrome throughout the nation are male with an average age of 24.  The majority (62 percent) of the perpetrators are the parent of the victim.  However, another high risk group is the live-in boy friend of the mother (20 percent).
• According to the same survey, 57 percent of the victims of shaken baby syndrome nationally are male with an average age of 8.9 months.
• In a recent study it was found that 31.2 percent of children who were clinically symptomatic after abusive head trauma were misdiagnosed as having other conditions. Jenny, C., Hymel, KP, et.al., Analysis of Missed Cases of Abusive Head Trauma,   JAMA, 281(7):  621-626.
• The National Information, Support and Referral Service on Shaken Baby Syndrome offers information to medical, legal, investigative, social work and prevention professionals as well as parents on the ramifications of shaken baby syndrome.  For more information about SBS or the National Information, Support and Referral Service on Shaken Baby Syndrome, contact the Service at 888-273-0071.

Information on Sexual Abuse

Sexually transmitted disease and pregnancy

Other physical indicators of sexual abuse include symptoms of sexually transmitted disease (STD) as well as pregnancy.  In a preteen child, abuse is strongly indicated if STD is present.  In a teenager, further information is needed about the circumstances and the child’s sexual partner, who might have been another minor about the same age, an older minor, or an adult.  Reasonable suspicions must be reported to CPS (1-800-252-5400) and/or law enforcement.

Other physical indicators of sexual abuse include symptoms of sexually transmitted disease (STD) as well as pregnancy.In a preteen child, abuse is strongly indicated if STD is present.In a teenager, further information is needed about the circumstances and the child’s sexual partner, who might have been another minor about the same age, an older minor, or an adult.Reasonable suspicions must be reported to CPS (1-800-252-5400) and/or law enforcement.

Specific behavioral indicators of sexual abuse

Children who have been sexually abused may be identified by their frequent expressions (verbal references, pictures, pretend games) of sexual activity between adults and children or by knowledge about sexual  relations beyond what is probable for their age.  They may masturbate inappropriately or compulsively.  Their behavior may be sexually suggestive, inappropriate, or promiscuous; or, conversely, they may show infantile behavior or extreme fear of being alone with adults of a particular sex.  A very strong indication that a child has been abused is that child’s sexual victimization of other children.

Symptoms of emotional injury

More generalized psychological impacts of sexual abuse include withdrawal, depression, sleeping and eating disorders, self-mutilation, phobias, and psychosomatic symptoms such as stomaches and headaches.  The child may develop school problems such as frequent absence or a sudden drop in grades.  The child may exhibit either poor hygiene or excessive bathing.  Older children may abuse alcohol or drugs, run away, or adopt other self-destructive behaviors including suicide threats or attempts.

What Can We Do About Child Abuse, Prepared by the Texas Office of the Attorney General, with the cooperation of the Crime Victims’ Compensation Division, the Texas Medical Association and Texas CASA, Inc.

History

• A child reports sexual activities to a friend, classmate, teacher, friend’s mother, or other trusted adult.  The disclosure may be direct or indirect (“I know someone....”; “What would you do if ...?”; “I heard something about somebody.”)  It is not uncommon for the disclosure by children experiencing chronic or acute sexual abuse to be delayed.
• Child wears torn, stained, or bloody underclothing. 
• Knowledge that a child’s injury/disease (vaginal trauma, sexually transmitted disease) is unusual for the specific age group.
• Knowledge of a child’s history of previous or recurrent injuries/ diseases. 
• Unexplained injuries/diseases (parent/caretaker unable to explain reason for injury/disease); there are discrepancies in explanation; blame is placed on a third party; explanations are inconsistent with medical diagnosis. 
• A young girl is pregnant or has a sexually transmitted disease.  Pregnancy of a minor, regardless of her age, does not in and of itself constitute the basis of reasonable suspicion of sexual abuse and should not be reported.  However, other information such as statements by the minor, indication of coercion or significant age disparity between the minor and her partner may lead to a reasonable suspicion of sexual abuse that must be reported.

Facts on Sexual Abuse of Children

• Offender is usually well-known to child
• Incest occurs within all socio-economic status
• Children rarely lie about sexual abuse
• Children often are blamed for the incestuous relationship
• Most often sexual abuse is initialized before child reaches puberty
• Rarely do children present with physical signs indicative of sexual abuse

Offender is usually well-known to child. Incest occurs within all socio-economic status. Children rarely lie about sexual abuse. Children often are blamed for the incestuous relationship. Most often sexual abuse is initialized before child reaches puberty. Rarely do children present with physical signs indicative of sexual abuse.

Indicators 

Behavioral Indicators of Sexually Abused Children

• Detailed and age-inappropriate understanding of sexual behavior (especially by younger children)
• Inappropriate, unusual, or aggressive sexual behavior with peers or toys.
• Compulsive indiscreet masturbation
• Excessive curiosity about sexual matters or genitalia (self and others)
• Unusually seductive with classmates, teachers, and other adults
• Excessive concern about homosexuality (especially by boys)
• Frightened of parents/caretaker or of going home

Behavioral Indicators in Younger Children

• Enuresis (bed wetting)
• Fecal soiling
• Eating disturbances (overeating, undereating)
• Fears or phobias
• Overly compulsive behavior
• School problems or significant change in school performance (attitude and grades)
• Age-inappropriate behavior (pseudomaturity or regressive behavior such as bed wetting or thumb sucking)
• Inability to concentrate
• Drastic behavior changes in and out of parents/caretaker presence
• Sleep disturbances (nightmares, fearful about falling asleep, fretful sleep pattern, or sleeping long hours)
• Speech disorders

Behavioral Indicators in Older Children and Adolescents

• Withdrawal
• Chronic fatigue
• Clinical depression, apathetic
• Overly compliant behavior
• Poor hygiene or excessive bathing
• Poor peer relations and social skills; inability to make friends
• Acting out, runaway, aggressive, antisocial, or delinquent behavior
• Alcohol or drug abuse
• Prostitution or excessive promiscuity
• School problems, frequent absences, sudden drop in school performance
• Refusal to dress for physical education
• Nonparticipation in sports and social activities
• Fearful of showers/restrooms
• Fearful of home life demonstrated by arriving at school early or leaving late
• Suddenly fearful of other things (going outside, participating in familiar activities)
• Extraordinary fear of males (in cases of male perpetrator and female victim)
• Self-consciousness of body beyond that expected for age
• Sudden acquisition of money, new clothes or gifts with no reasonable explanation
• Suicide attempt or other self-destructive behavior
• Crying without provocation
• Fire setting

Physical Symptoms of Sexual Abuse

• Sexually transmitted diseases
• Genital discharge or infection.
• Physical trauma or irritations to the anal/genital area (pain, itching, swelling, bruising, bleeding, lacerations, abrasions, especially if unexplained or inconsistent)
• Pain upon urination/defecation
• Difficulty in walking or sitting due to genital or anal pain
• Psychosomatic symptoms (stomachaches, headaches)

Child Abuse Prevention Handbook, Crime Prevention Center, Office of Attorney General, Daniel E. Longron, Attorney General, California Dept. of Justice, March 1993.

Emotional Injury of a Child

The law recognizes the existence of both physical and emotional injury. Physical abuse is almost invariably accompanied by emotional injury to some degree: It is difficult to imagine that a child could suffer “substantial harm” as the result of a deliberate assault by a caregiver and not also be psychologically harmed. Moreover, angry parents who physically assault their children are likely to assault them verbally, too.

Forms of verbal assault

Emotional injury is inflicted on children by verbal assaults that may take the form of belittling, name-calling, screaming, threatening, blaming, and sarcasm. Other damaging verbal habits are referring to a child only as “it” or repeatedly telling the child that she is “worthless” or “bad.” Unwittingly makes comments such as “mommy always tells me I’m bad.”

Unpredictable responses, unreasonable demands

A child may suffer emotional harm when subjected to extremely unpredictable or inconsistent responses from caregivers. Unreasonable expectations and demands can also be harmful. A child may suffer serious psychological harm from being rejected, terrorized, ignored, or isolated emotionally.

Signs of emotional injury

Signs of emotional injury include many general symptoms that could result from causes other than emotional abuse. They include withdrawal, depression or apathy; behavior problems or “acting out;” or a child who is overly rigid in conforming to instructions from teachers, doctors, and other adults. An emotionally abused child may refuse verbal or physical communication with others, or express feelings of being bad or worthless. Symptoms such as these can be produced by emotional abuse, but because they may arise from other causes, they must always be considered in context.