Identifying signs of intentional injury in children

History tells us that intentional injury is not a new phenomenon: in 1860 a French pathologist Auguste Ambroise Tardieu wrote a forensic study on the cruelty and the ill treatment of children. While the terminology has evolved over time to be more encompassing, there is no definitive peak incidence, and therefore there is no ideal time for reminding emergency department nurses about this issue.

Paediatric nurses have a unique understanding and knowledge of the physical, cognitive, emotional and social development of the child and are therefore well placed in ED to recognise deviations from the norm. It is important that ED nurses recognise subtle signs of injury such as bruising, or constellations of injuries such as a subdural haematoma, rib fractures or retinal haemorrhages.

If these injuries are noted without a significant history then further investigations are warranted. Participating in timely mandatory education ensures nurses are aware of current resources and local reporting requirements. This may be the first or indeed the only presentation for this child to any health facility, therefore it is vital that ED nurses keep cognisant of intentional injury.

DEFINITION
Intentional injury is a term used for a deliberately inflicted physical injury. It can be divided into two categories: abuse by commission, or committing the act; and abuse by omission, or failing to protect (National Society for the Prevention of Cruelty to Children, 2017).

Intentional injury may include draconian or violent disciplining techniques, physical restraining techniques or assault.

Sexual abuse includes the involvement of a child in sexual activity that he or she does not comprehend and is unable to give informed consent to. The legal age of consent for sexual activity varies by jurisdiction across Australia but ranges from 15 to 18 years of age.

Emotional abuse or psychological maltreatment includes insecure attachment and bullying.

Neglect results from the failure to provide for the child’s physical and emotional needs (Smith, 2011).

Family violence where a child is present while a parent or sibling is intentionally abused is also increasingly recognised as a strong and potent risk factor for child abuse (Bancroft, 2004).

According to the World Health Organization, child abuse encompasses all forms of child maltreatment, intentional injury, sexual and emotional abuse as well as neglect and child cruelty. These terms are used interchangeably, but the focus of this article is on intentional injury, a deliberately inflicted injury.

PREVALENCE
Seventy years ago American paediatric radiologist John Caffey noted a correlation between long bone fractures and subdural haematomas in infants (Grover, 2016). He termed these injuries “whiplash shaken baby syndrome” in 1946. This is now known as abusive head trauma (Leventhal, 2012).

In 1962, German physician Henry Kempe expanded on Caffey’s observations and coined the term ‘the battered child’, which is now referred to as intentional injury.

The true incidence of intentional injury is difficult to quantify, perhaps due to the underfunding of rigorous national studies. It is also difficult to estimate the number of cases that are never reported or detected. However, according to Gilbert (2009) the trend in incidence appears to be increasing.

In 2012 the International Congress on Child Abuse and Neglect reported that 25–50 per cent of children around the world suffer from intentional injury annually. More recent US data suggests one in three children are maltreated in some manner and are reported to the local child protection services (National Data Archive on Child Abuse and Neglect, 2015).

According to Gilbert (2008), 4–16 per cent of children are victims of intentional injury every year in well-resourced countries like Australia. More recently, the Australian Institute of Health and Welfare reported that 3.2 per cent of Australian children required some form of child protection in 2015–16.

Intentional injury is rarely a ‘one time’ event. It is usually repetitive and often escalates (Gilbert, 2008; Finkelhor, 2008). There is significant mortality associated with intentional injury. In the US in 2015, more than 1600 child fatalities were attributed to child maltreatment (National Data Archive on Child Abuse and Neglect, 2015).

WARNING SIGNS
When a child presents to the ED, nurses follow the ABC – airway, breathing and circulation – to start the primary survey for patient assessments. Extrapolating the ABC principle to ‘Always Be aware of Child abuse’ can hone nursing skills to identify both subtle and more obvious signs of intentional injury.

It is estimated that 1–10 per cent of paediatric injuries seen in the ED are intentional (Narang, 2014). Five critical questions for the ED nurse to assess are:

1. Is the history consistent with the injury?
2. Is the injury consistent with the developmental age of the child?
3. Are there unexplained or multiple injuries with different ages of healing?
4. Is there a delay in presentation for medical assessment? (The natural response is to seek medical advice early.)
5. Is the child’s behaviour culturally appropriate?

Intentional injury should be considered when a child exhibits evidence of a fracture of any bone, or a subdural haematoma, soft tissue swelling, or skin bruising – especially if there are patterns to the bruising (NSPCC and Cardiff University, 2012).

In cases where a child dies suddenly, and the degree and type of injury does not match the history given, the story seems implausible, or the story is inconsistent, investigation of intentional injury is warranted (Neal, 2015).

In keeping with the findings from the American Academy of Pediatrics (2014), it is likely that the child will present with ‘minor’ or subtle injuries, such as a torn oral frenulum (which usually follows a slap or blunt injury to the face, or it may indicate sexual abuse) or perhaps scattered bruising. Certain fractures are more likely to be associated with child abuse such as posteromedial rib fractures or metaphyseal long bone fractures.

It is rare that there will be overt signs of intentional injury on a child such as gunshot residue at the temple of a child’s head, or evidence of cigarette burns on the exposed upper limbs, or the stocking and glove marks from a deliberate hot water scald injury. On rare occasions, the child may only present in extremis – at the point of death (Glick, 2016).

Bruising, on the other hand, is one of the most common and readily visible injuries resulting from intentional injury. However, it may be overlooked because it is deemed to be clinically insignificant or ‘minor’.

The TEN-4 rule uses a combination of anatomy and age to predict inflicted injury (Pierce, 2009). It describes bruising on the torso, ears and neck (TEN) or bruising anywhere on a child younger than and including four months of age, as a red flag that may be indicative of intentional injury. TEN-4 also includes any of the TEN areas on a child younger than four years of age.

Patterns, shapes and numbers of bruising, and those away from bony prominences, should always be of concern to ED nurses.

RECOGNITION AND REPORTING
Throughout Australia, nurses are bound bylaw to report cases where intentional injury and sexual abuse are suspected. Each state and territory has its own legislation stipulating who is mandated to report suspected cases of harm or risk of harm.

Most paediatric hospitals have their own internal child advocacy services which offer investigative follow-up while these children are inpatients. At our trauma centre, our Child Protection and Forensic Medical Service liaises with the Queensland Police Service and the Department of Communities, Child Safety and Disability Services (DCCSDS).

In Queensland, a notification of a case is sent to the DCCSDS. Its role is to investigate concerns that a child has been harmed or is at risk of significant harm, and to provide ongoing support to such children that are in need of protection. Substantiations occur when an investigation has concluded and there is reasonable cause to believe that the child had been, was being, or was likely to be, abused, neglected or otherwise harmed.

From a medical treatment perspective, extensive investigations may be undertaken to rule out numerous other confounding diagnoses. In the hospital, these investigations include a thorough history-taking and physical assessment with accurate documentation. Other investigations may include laboratory investigations on clotting time and vitamin levels, ophthalmology exams, bone and brain scans, and metabolic, genetic and ‘failure to thrive’ screening.

IMPACT ON THE CHILD
If ED nurses do not recognise and report intentional injury, these missed opportunities potentially fail the child. The child’s welfare is paramount to the paediatric ED nurse, and intentional injury can have a detrimental effect on a child’s health, development and wellbeing (Finkelhor 2008, Bancroft 2004).

SUPPORT SERVICES
ED nurses serve a vital role in critically assessing the situation, initiating the investigations and making the mandatory report with law enforcement child protection services for the safety and protection of the child. It is important that ED nurses are able to provide supportive resources to the parents and families, such as positive parenting and prevention programs as well as cultural competence.

Resources for children identified as being at risk of intentional injury include access to social workers, mental health clinicians, counsellors, therapists, psychologists and support groups.

Through one-on-one sessions, group therapy or online forums, they can be guided through the steps of mourning and grief to healing and recovery. As Levine (1997) says, all humans have an innate capacity to triumph over trauma given the right support, and there are many groups worldwide helping to provide this support.

IMPACT ON THE NURSE
Given the compelling morbidity and mortality associated with intentional injury, it is not surprising that caring for these children can have an emotional impact on the paediatric ED nurse. Empathetic caring and interpersonal skills are at the core of professional nursing practice and the relationship between a paediatric nurse and child.

In situations where the ED nurse is exposed to repeated or particularly distressing cases of intentional injury, they may experience compassion fatigue (Figley, 2002). If not addressed, this may have a negative impact on the ED nurse leading to burnout, absenteeism, depression, professional crisis or early retirement (Koffske, 2016).

Although local registration authorities such as the Australian Health Practitioner Regulation Agency set professional ethical codes of practice for nurses, personal moral codes may be challenged as perpetrators are treated with the same respect as every other parent. This may place extra demands on the nurse’s emotional reserve. To counter this, being deliberately proactive in self-resilience training as well as ensuring adequate nutrition, hydration, sleep and exercise may protect against compassion fatigue (Koffske, 2016).

Some progressive institutions offer supportive counselling or mentoring programs to their staff, such as the Employee Assistance Program, which is available throughout Australia and has the potential to positively impact a robust and enduring workforce (Stone, 1999).

CONCLUSION
ED nurses are aware of the unique challenges associated with caring for paediatric patients.

Always being aware of child abuse and intentional injury fits easily within the scope and practice of paediatric ED nurses, as they take a comprehensive view of the child’s needs.

Recognising intentional injury takes experience, sensitivity and courage. It involves mandatory reporting, facilitating the investigations, treating the clinical needs and assisting with safe disposition of the child.

Having a high index of suspicion for intentional injury, in conjunction with specifically developed tools such as the TEN-4 rule, will enable both attention to detail and objectivity in this regard.

Compassion and empathy are fundamental skills of the paediatric nurse, and developing proactive selfcare strategies will help build emotional resilience. Actively prioritising personal mental and physical health with focused individualised goals will help health professionals with adversity, replenish energy levels, and enable them to be empathetic, compassionate, focused and optimistic about the future.

Providing meaningful interventions and resources will promote happy, healthy, well-adjusted children to grow into responsible young adults and ultimately become role models themselves for the next generation.

Children deserve the best possible chance to rebuild their lives, and to endure, after intentional injury. As Nelson Mandela said: “We owe our children, the most vulnerable citizens in our society, a life free of violence and fear.”

Tona Gillen is nurse manager, trauma, at Lady Cilento Children’s Hospital in South Brisbane.

Kids Helpline can be reached on 1800 55 1800 or Lifeline on 13 11 14 or ChildLine UK 0800 1111

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