WHENEVER we think of child abuse, images of internal bleeding into the brain (intracranial haemorrhage), fracture of the long bones of the limbs and skull fracture among children age one month to five years seldom come to mind. Why? Perhaps because we cannot conceive of people deliberately hurting infants and children that young.

However, in traditional paediatric practice, every unexplained injury in very young children should be suspected to be one of child abuse until proven otherwise. The child’s caregiver – whether parent, guardian, or babysitter – may have particular goals that differ from those of the attending doctor. However, in-between the two aims, the ‘correct’ diagnosis must be reached. Consequently, broad inclusion of elements derived from the medical, developmental and family history must be included by the doctor in order to make a wide differential diagnosis in every case of suspected child abuse.

Medically evaluating child abuse

Important considerations here include past injuries and fractures, estimated gestational age (how far along the pregnancy went), and birth complications if the child is of age less than six months, as well as any parental concerns for the child’s development. The specific nature of the injury, a history of easy bleeding or seizures (‘epileptic fits’ can be caused by bleeding inside the skull), or potential dietary insufficiencies (of importance in long bone fractures), are also important considerations.

Laboratory testing should also be done, including screening for coagulation disorders (that can cause bleeding), hidden abdominal trauma in children presenting with intracranial bleeding, as well as testing for bone health in those having long bone (limb) fracture. CT scan and skeletal radiography (X-rays) are also recommended when available.

Psychosocial elements are always important in these cases, and so a description of the child-care setting in cases of intracranial bleeding or skull fracture, and any prior history of abuse should be obtained. In addition, specific enquiries about any violence in the home must be made as this is a risk factor for abuse and a mechanism for injury.

Other important psychosocial considerations include a description of the caregiver’s mental health, any history of substance abuse, details regarding the pregnancy being planned or not (where the abused is an infant), and parental perceptions of the child’s temperament or behaviour. We should always bear in mind that abusive head trauma always has deep, prolonged effects in children.

Excluding alternative diagnoses

Diagnosing child abuse in the very young or in those children who are unable to explain, is often a matter of excluding alternative diagnoses, and is a process with no clearly defined end point. The process is uncertain, and so an overly broad approach must be taken. There is no written, specific guidance, and so each doctor must screen through all the possible signs and symptoms to ensure reliability and accuracy in diagnosis. Certainly, there will be a need for an extensive medical history, assessment of the ‘source’ of the history, the caregiver present at the time of the injury and their response to the symptoms, and any changes or discrepancy in the history provided.

The concern will be for possible future adversities for the child and family, and so the psychosocial history, (involving both psychological and social aspects), will be important. More research into this important area of public health is needed to ascertain the most effective approaches, mechanisms and tools to reduce child abuse, as the consequences to affected children may carry long-term physical as well as mental health effects (psychological scarring; consequent anti-social behaviour; chronic anxiety; depression, etc).

Duty to report

Under Jamaica’s Child Care and Protection Act, a physician, nurse, dentist, and other health or mental health professional, administrator of a hospital facility, school principal, teacher or other teaching professional, social worker or other social service professional, any owner, operator, or employee of a child day-care centre or other child-care institution, a guidance counsellor or any other person who by virtue of his or her employment or occupation has a responsibility to discharge a duty of care towards a child, or any person who has information that causes that person to suspect that a child has been or is likely to be abused, is required by law to make a report to the Children’s Registry (or the nearest police station).

Any person who fails to make this report is deemed to have committed an offence and shall be liable upon conviction to a fine not exceeding $500,000 or to imprisonment to a term not exceeding six months, or to both.

Consequently, we all have the responsibility to be on the lookout for possible abuse to children from as early as a few months of age. It happens!

Derrick Aarons MD, PhD is a consultant bioethicist/family physician, a specialist in ethical issues in medicine, the life sciences and research, and is the ethicist at the Caribbean Public Health Agency – CARPHA. (The views expressed here are not written on behalf of CARPHA).