Psychosocial risk factors and prior unexplained bruising herald escalating abuse.
Analysis of fatal and near–fatal physical abuse cases of children under 4 years of age revealed that psychosocial risk factors in the home, such as criminal history, were present in all cases. Two–thirds of the cases with prior medical records available (nine children) involved unexplained or atypical bruising – bruises on non–mobile infants, bruises on the ears, buttocks or eyes, and patterned bruises consistent with inflicted injury. All nine of these children suffered subsequent brain injury, resulting in four deaths.

Findings were published in the journal Child Abuse & Neglect.

“Our study highlights the unfortunately missed opportunities to intervene when unexplained or atypical bruising was noted, allowing children to remain in high–risk environments where more severe or fatal injuries later occurred,” says Mary Clyde Pierce, MD, from Stanley Manne Children’s Research Institute at Ann & Robert H. Lurie Children’s Hospital of Chicago. “We need to raise awareness that atypical bruising in young children may signal child abuse and must be investigated to prevent escalating harm.”

Each year, approximately 3 million children are the subjects of reports to state child protection agencies, and around 1,500 children are fatally injured from identified maltreatment, according to the U.S. Department of Health and Human Services.

Pierce and colleagues conducted retrospective state record reviews of 20 near–fatal and fatal physical child abuse cases from the Commonwealth of Kentucky. The majority of children were under 1 year of age. The commonalities they found included psychosocial risk factors (100 percent), traumatic brain injury (90 percent), bruising (80 percent), fractures (35 percent), absence of a trauma history at initial presentation (80 percent), male caregiver at the time of the fatal or near–fatal event (70 percent) and prior unexplained bruising (50 percent).

Data was abstracted from all available medical, social and legal documents, and such comprehensive access allowed researchers to gain a more complete understanding of the children’s history, environment and injuries.

The majority of child abuse cases in the study were associated with four or more psychosocial risk factors. These include criminal history, prior child social service involvement, domestic or intimate partner violence, negative interpretations of the child’s behaviors, and mental health problems or substance abuse.

“Although the predictive value of each of the commonalities we identified cannot be determined from this case series study, our findings will help guide future prospective studies in larger populations,” says Pierce, an Emergency Medicine physician at Lurie Children’s and Professor of Emergency Medicine at Northwestern University Feinberg School of Medicine. “Our ultimate goal is to inform collaborative strategies for child abuse prevention.”