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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.

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.

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).

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.

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.

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).

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.

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).

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


Australian Institute of Health and Welfare (AIHW) 2016, CFCA Resource Sheet (October 2016) Child abuse and neglect statistics

Australian Institute of Health and Welfare (AIHW) 2017, Child Protection

American Academy of Paediatrics report (2014) Evaluating Children with Fractures for Child Physical Abuse

Anne Smith MBBS, FRACP, (2011) Non-Accidental Injury Australian Family Physician Vol. 40, No. 11

R. Lundy Bancroft (2004) The Batterer as Parent: Addressing the Impact of Domestic Violence on Family Dynamics (SAGE Series on Violence against Women) 1st Edition

Crane Jennifer(2015) ‘The bones tell a story the child is too young or too frightened to tell’: The Battered Child Syndrome in Post-war Britain and America

Cradock Gerald (2014) Who Owns Child Abuse?

Norman Doidge (2010) The Brain That Changes Itself. Stories of Personal Triumph from the Frontiers of Brain Science.

Prof Ruth Gilbert, MD Alison Kemp, FRCPCH Prof June Thoburn, LittD Peter Sidebotham, PhD Lorraine Radford, PhD Danya Glaser, FRCPsych Prof Harriet L MacMillan,MD. (2008) Recognising and responding to child maltreatment

Michael D. De Bellis, MD, MPH and Abigail Zisk A.B.(2014) The Biological Effects of Childhood Trauma

Jennifer Delima and Graham Vimpani (2011) The neurobiological effects of childhood maltreatment.

David Finkelhor (2008) Childhood Victimization. Violence, crime, and abuse in the lives of young people.

Figley CR (2002) Compassion fatigue: Psychotherapists’ chronic lack of self care. Journal of Clinical Psychology.

Figley CR (1995) Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized.

Figley CR (2002) Treating Compassion Fatigue. 2002 New York: Brunner/Routledge.
Herron, L. Stressing the importance of dealing with stress. 2010 . Ohio Nurses Review, 85(5).

Prof Ruth Gilbert Prof Cathy Spatz Widom, PhD Prof Kevin Browne, PhD David Fergusson, PhD Elspeth Webb, FRCPCH Prof Staffan Janson, DM (2008) Burden and consequences of child maltreatment in high-income countries.

Jill C. Glick, Michele A. Lorand, Kristen R. Bilka (2016) Physical Abuse of Children.

Casey A. Grover, MD and Elizabeth Crawford, BS (2016) John Caffey: Shaken Infant Syndrome The Journal of Emergency Medicine.

Emily A. Greenfield (2010) Child abuse as a life-course social determinant of adult health.

Higham, Sue (2010) Holistic practice in children's nursing; the personal, professional and maternal.

Kathleen Kendall-Tackett, Ph.D. (2002) The Health Effects of Childhood Abuse: Four Pathways by which Abuse Can Influence Health

C. Henry Kempe, M.D.; Frederic N. Silverman, M.D.; Brandt F. Steele, M.D.; William Droegemueller, M.D.; Henry K. Silver, M.D. (July 7, 1962) The Battered-Child Syndrome

Kempe CH, Helfer, RE. (1983) The Battered Child (3rd ). Chicago: University of Chicago Press.

John M. Leventhal, MD Julie R. Gaither,RN, MPH, MPhil (2012) Incidence of Serious Injuries Due to Physical Abuse in the United States: 1997 to 2009

Jean Labbé (2005) Ambroise Tardieu The Man and his Work on Child Maltreatment a Century before Kempe’ Child Abuse & Neglect. 29(4):311–324

Mathews, B., Walsh, K., Dunne, M., Katz, I., Arney, F., Higgins, D., Octoman, O., Parkinson, S., & Bates, S. (2016) Scoping study for research into the prevalence of child abuse in Australia: Report to the Royal Commission into Institutional Responses to Child Sexual Abuse. Sydney: Social Policy Research Centre (SPRC Report 13/16), UNSW Australia in partnership with Australian Institute of Family Studies, Queensland University of Technology and the Australian Centre for Child Protection (University of South Australia).

Ben Neal (2015) Paediatric physical abuse: 4 tips to recognize it during the physical exam. Suspect physical abuse of a child when there is a mismatch between the reported mechanism of injury, patient history and the physical exam finding.

Narang, et al. (2014) Legal Issues in Child Maltreatment Pediatr Clin North America

Mary Clyde Pierce, MD ,Kim Kaczor, MS,Sara Aldridge, MSN, ARNP, Justine O’Flynn, RN, Douglas J. Lorenz, MA, MSPHc. (July 2009) Bruising Characteristics Discriminating Physical Child Abuse From Accidental Trauma

Nutbeam D. (2000) Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International. 2000;15(3):259–267.

Ogden, P., Minton, K., and Pain, C. (2006) Trauma and the body: A sensorimotor approach to psychotherapy. New York: W.W. Norton.

Christina Paxson, Jane Waldfogel (1999) Work, Welfare, and Child Maltreatment, National Bureau of Economic Research 1050 Massachusetts Ave., Cambridge, MA 02138
Peter A. Levine Ann Frederick (1997) Waking the Tiger: Healing Trauma: The Innate Capacity to Transform Overwhelming Experiences by North Atlantic Books (first published 1997)
Perry, Bruce D. (2013) Bonding and attachment in Maltreated Children. Consequences of Emotional Neglect

Pinheiro P 2006. World report on violence against children. New York: UNICEF.

Paola Ferri, Jennifer Muzzalupo, and Rosaria Di Lorenzo (2015) Patients’ perception of dignity in an Italian general hospital: a cross-sectional analysis.

Renkert S, Nutbeam D (2001) Opportunities to improve maternal health literacy through antenatal education: An exploratory study. Health Promotion International. 2001;16(4):381–388

Barbara Koffske Reid (2016) Annual Scientific Assembly in San Antonio. In a session entitled ‘Caring for the Elephant in the Room’

David Shemmings (2011) Indicators of disorganised attachment in children. Community Care and Community Care
Florence M. Stone (1999) Coaching, Counselling & Mentoring: How to Choose & Use the Right Technique to Boost Employee Performance New York: American Management Association

Tjale AA, Bruce J.(2007) A concept analysis of holistic nursing care in paediatric nursing

https://www.aihw.gov.au (Australian Institute of Health and Welfare)

http://www.ahpra.gov.au/registration/registers-of-practitioners.aspx (Australian Health Practitioner Regulation Agency)

http://search.abs.gov.au/s/search.html?query=criminal+courts+2012-2013 (Australian Bureau of Statistics)

http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment National Data Archive on Child Abuse and Neglect (NDACAN) USA


http://www.abs.gov.au/ausstats/[email protected]/Previousproducts/3101.0Main%20Features1Jun%202016?opendocument&tabname=Summary&prodno=3101.0&issue=Jun%202016&num=&view

http://www.abs.gov.au/ausstats/[email protected]/Previousproducts/3101.0Feature%20Article1Jun%202016?opendocument&tabname=Summary&prodno=3101.0&issue=Jun%202016&num=&view




Indicators of disorganised attachment in children


http://www.futureswithoutviolence.orgk (Mission Australia)

https://www.gov.uk/government/statistics/characteristics-of-children-in-need-2015-to-2016http://www.euro.who.int/__data/assets/pdf_file/0019/217018/European-Report-on-Preventing-Child-Maltreatment.pdfhttp://www.thejournal.ie/child-abuse-reports-3276951-Mar2017/ https://www.qfcc.qld.gov.au/annual-report-deaths-children-and-young-people-queensland-2014%E2%80%9315

https://www.joomag.com/magazine/nursing-review-issue-6-nov-dec-2016/0391220001479077887?short (Compassion Fatigue)


https://www.nspcc.org.uk (National Society for the Prevention of Cruelty to Children,2017)



http://pact.org.au/ (Protect all Children Today)

Self-care strategies can help trauma providers overcome stress, burnout and compassion fatigue

http://www.who.int/features/factfiles/violence/en/ (World Health Organisation)




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