Battered child syndrome

Definition

Battered child syndrome (BCS) refers to non-accidental injuries sustained by a child as a result of physical abuse, usually inflicted by an adult caregiver.

Description

Internal injuries, cuts, burns , bruises , and broken or fractured bones are all possible results of battered child syndrome. Because adults are so much larger and stronger than children are, an abused can suffer severe injury or death without the abuser intentionally causing such an injury. Shaking an infant can cause bleeding in the brain (subdural hematoma ), resulting in permanent brain damage or death. Emotional damage to a child is also often the byproduct of child abuse , which can result in the child exhibiting serious behavioral problems such as substance abuse or the physical abuse of others.

BCS is alternatively referred to as child physical abuse or non-accidental trauma (NAT).

Demographics

The total abuse rate of children is 25.2 per 1,000 children, with physical abuse accounting for 5.7 per 1,000, sexual abuse 2.5 per 1,000, emotional abuse 3.4 per 1,000, and neglect accounting for 15.9 per 1,000 children. These categories overlap, with sexual and physical abuse often occurring together; physical abuse or neglect seldom occur without emotional abuse. These numbers may be underestimates due to underreporting of the problem or failure of diagnosis by medical personnel.

In 1996, more than 3 million victims of alleged abuse were reported to child protective services in the United States; reports were substantiated in more than one million cases. Parents were abusers in 77 percent of the confirmed cases; other relatives in 11 percent. More than 1,000 children died from abuse in 1996.

Causes and symptoms

Causes

Battered child syndrome (BCS) is found at every level of society, although the incidence may be higher in lower-income households, where adult caregivers may suffer greater stress and social difficulties and have a greater lack of control over stressful situations. Other risk factors include lack of education, single parenthood, and alcoholism or other drug addictions. The child abuser most often injures a child in the heat of anger or during moments of stress. Common trigger events that may occur before assaults include incessant crying or whining of infants or children; perceived excessive "fussiness" of an infant or child; a toddler's failed toilet training ; and exaggerated perceptions of acts of "disobedience" by a child. Sometimes cultural traditions may lead to abuse, including beliefs that a child is property, that parents (especially males) have the right to control their children any way they wish, and that children need to be toughened up to face the hardships of life. Child abusers were often abused as children themselves and do not realize that abuse is not an appropriate disciplinary technique. Abusers also often have poor impulse control and do not understand the consequences of their actions.

Symptoms

Symptoms may include a delayed visit to the emergency room with an injured child; an implausible explanation of the cause of a child's injury; bruises that match the shape of a hand, fist or belt; cigarette burns; scald marks; bite marks; black eyes; unconsciousness; lash marks; bruises or choke marks around the neck; circle marks around wrists or ankles (indicating twisting); separated sutures; unexplained unconsciousness; and a bulging fontanel in small infants.

Emotional trauma may remain after physical injuries have healed. Early recognition and treatment of these emotional "bruises" is important to minimize the long-term effects of physical abuse. Abused children may exhibit:

• a poor self-image
• sexual acting out
• an inability to love or trust others
• aggressive, disruptive, or illegal behavior
• anger, rage, anxiety , or fear
• self-destructive or self-abusive behavior
• suicidal thoughts
• passive or withdrawn behavior
• fear of entering into new relationships or activities
• school problems or failure
• sadness or other symptoms of depression
• flashbacks or nightmares
• drug or alcohol abuse

Sometimes emotional damage of abused children does not appear until adolescence or even later, when abused children become abusing parents who may have trouble with physical closeness, intimacy, and trust. They are also at risk for anxiety, depression, substance abuse, medical illnesses, and problems at school or work. Without proper treatment, abused children can be adversely affected throughout their life.

When to call the doctor

Anyone should call a health care provider or child protective services if they suspect or know that a child is being abused. Reporting child abuse to authorities is mandatory for doctors, teachers, and childcare workers in most states as a means to prevent continued abuse.

Diagnosis

Battered child syndrome is most often diagnosed by an emergency room physician or pediatrician, or by teachers or social workers. Physical examination will detect injuries such as bruises, burns, swelling, retinal hemorrhages (bleeding in the back of the eye), internal damage such as bleeding or rupture of an organ, fractures of long bones ore spiral-type fractures that result from twisting, and fractured ribs or skull. X rays , and other imaging techniques, such as MRI or scans, may confirm or reveal other internal injuries. The presence of injuries at different stages of healing (i.e., having occurred at different times) is nearly always indicative of BCS. Establishing the diagnosis is often hindered by the excessive cautiousness of caregivers or by actual concealment of the true origin of the child's injuries, as a result of fear, shame and avoidance or denial mechanisms.

Treatment

Medical treatment for battered child syndrome will vary according to the type of injury incurred. Counseling and the implementation of an intervention plan for the child's parents or guardians are necessary. The child abuser may be incarcerated, and/or the abused child removed from the home to prevent further harm. Decisions regarding placement of the child with an outside caregiver or returning the child to the home will be determined by an appropriate government agency working within the court system, based on the severity of the abuse and the likelihood of recurrence. Both physical and psychological therapy are often recommended as treatment for the abused child. If the child has siblings, the authorities should determine where they have also been abused, for about 20 percent of siblings of abused children are also shown to exhibit signs of physical abuse.

Prognosis

The prognosis for battered child syndrome will depend on the severity of injury, actions taken by the authorities to ensure the future safety of the injured child, and the willingness of parents or guardians to seek counseling for themselves as well as for the child.

Prevention

Recognizing the potential for child abuse and the seeking or offering of intervention, counseling, and training in good parenting skills before battered child syndrome occurs is the best way to prevent abuse. The use of educational programs to teach caregivers good parenting skills and to be aware of abusive behaviors so that they seek help for abusive tendencies is critical to stopping abuse. Support from the extended family , friends, clergy, or other supportive persons or groups may also be effective in preventing abuse. Signs that physical abuse may occur include parental alcohol or substance abuse; high stress factors in the family life; previous abuse of the child or the child's siblings; history of mental or emotional problems in parents; parents abused as children; absence of visible parental love or concern for the child; and neglect of the child's hygiene.

Parental concerns

Parents who are in danger of abusing their children (for example, when they find themselves becoming inappropriately or excessively angry in response to a child's behavior) should seek professional counseling. Parents may also call the National Child Abuse Hotline (800-4-A-Child; 800-422-4453, a nationwide 24-hour telephone hotline), where they will be counseled through a parenting or caretaking crisis and offered guidance about how to better handle the situation.

Parents should also exercise caution in arranging for or hiring babysitters and other caretakers. If they suspect abuse, they should immediately report those suspicions to the police or to their local child protective services agency. They should also teach their children to report abuse to a trusted adult.

KEY TERMS

Child protective services (CPS) —The designated social services agency (in most states) to receive reports, investigate, and provide intervention and treatment services to children and families in which child maltreatment has occurred. Frequently this agency is located within larger public social service agencies, such as Departments of Social Services.

Fontanelle —One of several "soft spots" on the skull where the developing bones of the skull have yet to fuse.

Multiple retinal hemorrhages —Bleeding in the back of the eye.

Subdural hematoma —A localized accumulation of blood, sometimes mixed with spinal fluid, in the space between the middle (arachnoid) and outer (dura mater) membranes covering the brain. It is caused by an injury to the head that tears blood vessels.

Resources

BOOKS

Besharov, Douglas J. Recognizing Child Abuse: A Guide for the Concerned. New York, NY: Free Press, 1990.

Crosson-Tower, Cynthia. Understanding Child Abuse and Neglect. 5th Edition. New York, NY: Allyn & Bacon, 2001.

Feinen, Cynthia, Winifred Coleman, Margaret C. Ciocco, et al., eds. Child Abuse: A Quick Reference Guide. Long Branch, New Jersey: Vista Publishing, 1998.

Giardino, Angelo P., and Giardino, Eileen. Recognition of Child Abuse for the Mandated Reporter, 3rd ed. St. Louis, MO: G.W. Medical Publishing, 2002.

Lukefahr, James L. Treatment of Child Abuse. Baltimore, MD: Johns Hopkins University Press, 2000.

Monteleone, James A. A Parent's & Teacher's Handbook on Identifying and Preventing Child Abuse: Warning Signs Every Parent and Teacher Should Know. St. Louis, MO: G.W. Medical Publishing, 1998.

Reece, Robert, and Stephen Ludwig. Child Abuse: Medical Diagnosis and Management, 2nd ed. Baltimore, MD: Lippincott, Williams, and Wilkins, 2001.

ORGANIZATIONS

National Child Abuse Hotline. 800-4-A-Child (800-422-4453).

National Clearinghouse on Child Abuse and Neglect Information. P.O. Box 1182, Washington, DC 20013-1182. 800-394-3366. Web site: <http://nccanch.acf.hhs.gov>.

Prevent Child Abuse America. 200 South Michigan Avenue, 17th Floor, Chicago, IL 60604. (312) 663-3520. Web site: <http://preventchildabuse.org>.

National Parents Anonymous. 675 West Foothill Blvd., Suite 220m Claremont, CA 91711. (909) 621-6184. Web site: <http://www.parentsanonymous.org/pahtml/paNPLTabout.html>.

WEB SITES

Child Abuse: Types, Symptoms, Causes, and Help. Available online at: <http://www.helpguide.org/mental/child_abuse_physical_emotional_sexual_neglect.htm>.

"State by State Abuse Hotline & Organization Directory." The Broken Spirits Network. Available online at: <http://www.brokenspirits.com/directory>.

Judith Sims Mary Jane Tenerelli, MS

Battered Child Syndrome

Definition

Battered child syndrome refers to injuries sustained by a child as a result of physical abuse, usually inflicted by an adult caregiver. Alternative terms include: shaken baby; shaken baby syndrome; child abuse; and non-accidental trauma (NAT).

Description

Internal injuries, cuts, burns, bruises and broken or fractured bones are all possible signs of battered child syndrome. Emotional damage to a child is also often the by-product of child abuse, which can result in serious behavioral problems such as substance abuse or the physical abuse of others. Approximately 14% of children in the United States are physically abused each year, and an estimated 2,000 of those children die as a result of the abuse. Between 1994–1995, 1.1 million cases of child abuse were recorded in the United States; of that number, 55% of the victims were less than a year old.

Causes and symptoms

Battered child syndrome (BCS) is found at every level of society, although the incidence may be higher in low-income households where adult caregivers suffer greater stress and social difficulties, without having had the benefit of higher education. The child abuser most often injures a child in the heat of anger, and was often abused as a child himself. The incessant crying of an infant or child may trigger abuse. Symptoms may include a delayed visit to the emergency room with an injured child; an implausible explanation of the cause of a child's injury; bruises that match the shape of a hand, fist or belt; cigarette burns; scald marks; bite marks; black eyes; unconsciousness; bruises around the neck; and a bulging fontanel in infants.

Diagnosis

Battered child syndrome is most often diagnosed by an emergency room physician or pediatrician, or by teachers or social workers. Physical examination will detect bruises, burns, swelling, retinal hemorrhages. X rays, and other imaging techniques, such as MRI or scans may confirm fractures or other internal injuries. The presence of injuries at different stages of healing (i.e. having occurred at different times) is nearly always indicative of BCS. Establishing the diagnosis is often hindered by the excessive cautiousness of caregivers or by actual concealment of the true origin of the childþs injuries, as a result of fear, shame and avoidance or denial mechanisms.

Treatment

Medical treatment for battered child syndrome will vary according to the type of injury incurred. Counseling and the implementation of an intervention plan for the child's parents or guardians is necessary. The child abuser may be incarcerated, and/or the abused child removed from the home to prevent further harm. Reporting child abuse to authorities is mandatory for doctors, teachers, and childcare workers in most states as a way to prevent continued abuse. Both physical and psychological therapy are often recommended as treatment for the abused child.

Prognosis

The prognosis for battered child syndrome will depend on the severity of injury, actions taken by the authorities to ensure the future safety of the injured child, and the willingness of parents or guardians to seek counseling for themselves as well as for the child.

Prevention

Recognizing the potential for child abuse in a situation, and the seeking or offering of intervention and counseling before battered child syndrome occurs is the best way to prevent it. Signs that physical abuse may be forthcoming include parental alcohol or substance abuse; previous abuse of the child or the child's siblings; history of mental or emotional problems in parents; parents abused as children; absence of visible parental love or concern for the child; child's hygiene neglected.

KEY TERMS

Fontanel— Soft spot on top of an infant's skull.

Subdural hematoma— Bleeding over the brain.

Multiple retinal hemorrhages— Bleeding in the back of the eye.

Resources

BOOKS

Lukefahr, James L. Treatment of Child Abuse. Baltimore, MD: Johns Hopkins University Press, 2000.

PERIODICALS

Mulryan, Kathleen, "Protecting the Child." Nursing (July 2000).

ORGANIZATIONS

Childhelp National Abuse Hotline. (800)422-4453.

Battered child syndrome

A group of physical and mental symptoms arising from long-term physical violence against a child.

Battered child syndrome occurs as the result of long-term physical violence against a child or adolescent. An estimated 2,000 children die each year in the United States from confirmed cases of physical abuse and 14,000 more are seriously injured. The battering takes many forms, including lacerations, bruises, burns, and internal injuries. In addition to the physical harm inflicted, battered children are at risk for an array of behavioral problems, including school difficulties, drug abuse, sexual acting out, running away, suicide , and becoming abusive themselves. Dissociative identity disorder , popularly known as multiple personality, is also common among abused children.

Detecting and preventing battered child syndrome is difficult because society and the courts have traditionally left the family alone. Out of fear and guilt , victims rarely report abuse. Nearly one-half of child abuse victims are under the age of one and therefore unable to report what is happening to them. The parents or guardians who bring a battered child to a hospital emergency room rarely admit that abuse has occurred. Instead, they offer complicated, often obscure, explanations of how the child hurt himself. However, a growing body of scientific literature on pediatric injuries is simplifying the process of differentiating between intentional and accidental injuries. For instance, a 1991 study found that a child needs to fall from a height of 10 ft (3m) or more to sustain the life-threatening injuries that accompany physical abuse. Medical professionals have also learned to recognize a spiral pattern on x rays of broken bones, indicating that the injury was the result of twisting a child's limb.

Once diagnosed, the treatment for battered children is based on their age and the potential for the parents or guardians to benefit from therapy. The more amenable the parents are to entering therapy themselves, the more likely the child is to remain in the home. For infants, the treatment ranges from direct intervention and hospital care to foster care to home monitoring by a social service worker or visiting nurse. Ongoing medical assessment is recommended in all types of treatment. For the preschool child, treatment usually takes place outside the home, whether in a day care situation, a therapeutic preschool, or through individual therapy. The treatment includes speech and language therapy, physical therapy, play therapy, behavior modification , and specialized medical care.

By the time the child enters school, the physical signs of abuse are less visible. Because these children may not yet realize that their lives are different from those of other children, very few will report that their mothers or fathers are subjecting them to gross physical injury. It is at this stage that psychiatric and behavioral disorders begin to surface. In most cases the children are removed from the home, at least initially. The treatment, administered through either group or individual therapy, focuses on establishing trust, restoring self-esteem , expressing emotions, and improving cognitive and problem-solving skills.

Recognizing and treating physical abuse in the adolescent is by far the most difficult. By now the teen is an expert at hiding bruises. Instead, teachers and health care professionals should be wary of exaggerated responses to being touched, provocative actions, extreme aggressiveness or withdrawal, assaulting behavior, fear of adults, self-destruction, inability to form good peer relationships, alertness to danger, and/or frequent mood swings. Detection is exacerbated by the fact that all teenagers exhibit some of these signs at one time or another.

Abused teens do not evoke as much sympathy as younger victims, for society assumes that they are old enough to protect themselves or seek help on their own. In truth, all teenagers need adult guidance. The behavior that the abused adolescent often engages in—delinquency, running away, and failure in school—usually evokes anger in adults but should be recognized as symptoms of underlying problems. The abused teen is often resistant to therapy, which may take the form of individual psychotherapy , group therapy , or residential treatment.

While reporting child abuse is essential, false accusations can also cause great harm. It is a good idea for anyone who suspects that a child is being physically abused to seek confirmation from another adult, preferably a non-relative but one who is familiar with the family. If the second observer concurs, the local child protective services agency should be contacted. The agency has the authority to verify reports of child abuse and make decisions about protection and intervention.

Unlike many other medical conditions, child abuse is preventable. Family support programs can provide parenting information and training, develop family skills, offer social support, and provide psychotherapeutic assistance before abuse occurs.

See also Child abuse

Mary McNulty

Further Reading

Ackerman, Robert J., and Dee Graham. Too Old to Cry: Abused Teens in Today's America. Blue Ridge Summit, PA:TAB Books, 1990.

Helfer, Ray E., M.D., and Ruth S. Kempe, M.D., eds. The Battered Child. Chicago: The University of Chicago Press, 1987.

Arbetter, Sandra. "Family Violence: When We Hurt the Ones We Love," Current Health 22, November 1995, p. 6.

Further Information

National Committee for Prevention of Child Abuse. 332 S. Michigan Avenue, Chicago, IL 60605, (312) 663-3520.