It was in the second half of the 20th century that society began to take greater notice of violence against children. Previous taboos were discarded, and attention began to be directed toward violence in the family and within small social groups. The reporting and investigation of child maltreatment, and the response to it, involve people from many different walks of life, ranging from parents, relatives, and acquaintances to child-care workers, teachers, association members, volunteers in children’s aid societies, Child Protection Offices, police officers, prosecutors, and judges. From the 1960s onward, the topic of child abuse and neglect has received more attention from physicians as well, above all from pediatricians, pediatric surgeons, specialists in child psychiatry and psychosomatic medicine, general practitioners, and forensic physicians (1).

In this review article, we will discuss all forms of violence against children except sexual and emotional abuse and their long-term consequences. Thus, this article will concern physical and emotional neglect, physical abuse, and Münchhausen syndrome by proxy. We will present typical case constellations and characteristic patterns of injury that should arouse the suspicion of child maltreatment. We will then outline the appropriate behavioral options in response to child maltreatment and the medical interventions that should be undertaken to protect children against it.

The learning objectives for the reader are the following:

•to be able to recognize and diagnose different varieties of child abuse from the typical patterns of injury that they cause;
•to be able to distinguish the different types of child maltreatment and to know their long-term consequences;
•to know the appropriate behavioral interventions and possible medical interventions that can be used to protect children better.

This article is based on a comprehensive, selective review of the literature and on the authors’ professional experience.

Child neglect is the most common type of child maltreatment and has the most serious long-term consequences. Its physical signs may enable it to be diagnosed medically; if not, it can be detected only through the emotional and behavioral abnormalities that it causes.

It is mainly the specialty discipline of forensic medicine that has concerned itself with the systematic classification and assessment of bodily injuries with respect to their causation by child abuse. The first major question to be answered is what type of physical force has been applied to create the injury. Most often, blunt trauma is the cause; other causes are thermal trauma and the so-called shaking trauma syndrome (STS) or shaken baby syndrome (SBS).

Münchhausen syndrome by proxy (MSBP), in which another person—usually the child’s mother—either fabricates or actually induces illness in the child, is still a little-known disorder. In general, the long-term emotional consequences of violence against children are still inadequately appreciated (2,3).

The prevalence of child maltreatment
According to older literature that was summarized in a review article in 1983, the prevalence of child maltreatment a generation or more ago was 2% in Sweden, 7.7% in Finland, and 10% to 15% in Germany (4,5). Reliable current figures from multiple different countries are not available, as far as the authors have been able to determine. The older data suffice nonetheless to indicate that people in different countries may well have a different understanding of what constitutes child abuse.

A study by questionnaire that was commissioned in 2002 by the German Federal ministry of Family Affairs yielded the following findings:

•26% of all parents in Germany reject physical punishment of their children.
•52% consider “a slap on the behind” appropriate.
•5% use a stick.
•17% consider “a sound thrashing” to be appropriate under some circumstances.

While the rate of child abuse among German parents is consistently said to lie under 10%, the corresponding figures for parents of other ethnic origins is 18% for Turkish families, 12% for immigrant families from the former Soviet Union, and 15% for families from the former Yugoslavia (5).

According to studies from the USA, nearly 80% of the persons committing child abuse are the custodial parents (and the biological parents in 90% of all such cases), and 6.6% are relatives. The same studies concluded that 56.5% of the abusers are women and 42.4% are men, while 75% of all abusers are under 40 years old (6).

History, physical examination, diagnostic assessment
The suspicion of child abuse
The suspicion of child abuse may arise because of the pattern of injury that is found, e.g., an injury at a site where blows are typically struck or with a typical appearance, such as parallel stripes (Figure 1jpgppt). The plausibility of the proposed mechanism of injury is of prime importance. Aside from this, a number of circumstances of other types can indicate the likelihood of child abuse (5,10,11):

•A child that has been injured through abuse is often not taken to the doctor immediately, but only after a delay.
•The history of the event as recounted to the doctor is inconsistent with the type of injury seen, the symptoms and signs, and/or the child’s developmental state.
•Further ongoing questioning elicits multiple different versions of the history of the event.
•Siblings are said to have caused the injury.
•It may be stated that the child injured himself or herself.
•The psychodynamic evaluation may yield evidence of child abuse when the parents behave defensively, instead of showing the appropriate empathy and concern.

History
As soon after the event as possible, a detailed account of the events leading to the injury should be obtained and documented. Who did what, when, and how? Who else was present? What action did the parents take? What type of first aid, if any, was administered? Was the child taken to the doctor immediately, or only after a delay? Had there been any preceding problems or fights? Are there any exceptional stresses in the family, including a possible family history of child abuse? What was the parents’ emotional reaction? (10)

Physical examination
The child should be fully undressed, and the whole body should be examined thoroughly, including the anogenital region. The growth parameters should also be measured and noted in percentiles. Injuries should be described precisely, with indications of their localization, size, shape, and nature. (For example, a typical, fresh injury of the “self-defense” type could be described as follows: extensor surface of right forearm, middle third, 3 × 2 cm ovoid swelling, well demarcated, bluish-purple.) When indicated, the contour of the injury should also be described, e.g., when this provides a clue toward the type of object with which the child was struck. All injuries should be measured and photographically documented.

Ancillary studies
According to the current interdisciplinary S2-AWMF guidelines of the German societies for general and social pediatrics and for pediatric surgery (see www.leitlinien.net), ancillary diagnostic studies should also be performed as indicated (11). When there is well-founded suspicion that a child under the age of 2 years has been abused, skeletal x-ray screening and a funduscopic examination are indicated, with skeletal scintigraphy (“bone scanning”) as a possible additional study. A head CT (computerized tomography) is often performed acutely in children with neurological abnormalities but should always be followed by magnetic resonance imaging (MRI). CT, MRI, and ultrasonography can be performed to assess suspected injuries to other bodily organs (skull, abdomen, heart, cerebral Doppler flow study; soft tissues, bone). Laboratory tests serve to differentiate child abuse from other potential diagnoses and to assess the extent of injuries (5,10,e2).

Psychodynamic evaluation
The patient’s psychosocial situation should be ascertained (personalities of the parents, temperament of the child, social status, relationship biography), and the ability of the person primarily caring for the child to empathize appropriately with the child’s condition should also be observed. Emotional coldness, inadequate empathy, and a defensive reaction to personal conflicts, reflecting a lack of introspection and unwillingness to think about the child’s situation, as well as a personal history of being abused may be indications that a parent is a potential child abuser (3). There are no “definite” intrapsychic or family-dynamic signs of child abuse being imminent or having already occurred. Psychological test findings pointing toward what is called “dissimulation” (i.e., marked defensiveness and selection of answers according to their perceived social desirability, producing “better-than-normal” findings in certain adults and adolescents) may provide a diagnostic indication of possibly imminent violence within the family (12).

Blunt trauma
Injuries caused by blunt trauma (hematomata, contusions, oral injuries) are the most common cause of presentation to a doctor’s office or hospital (seeBoxes 1gifpptand 2gifppt). Injuries due to sharp or penetrating trauma play a subordinate role. Injuries due to abuse must always be differentiated from accidental injuries, particularly when there is only a single injury. Sometimes, children are abused by choking or by blows to sensitive parts of the body. Blows inflicted with an object (stick, belt) often leave a typical, double-contoured pattern (Figure 1). Bruises from blunt trauma may indicate child abuse, depending on their localization, shape, and mechanism of origin. Suspicion can also be aroused by an unusual multiplicity of injuries, or by injuries in a child of inappropriate age for accidental trauma. Pre-mobile infants hardly ever have bruises of accidental origin (e3). Bruises whose shape indicates that they have been left behind by a very firm grasp are often found on the arms, or else—in infants and small children—on the chest. Bruises can be found in typical sites for falls (the forehead, tip of the nose or chin, extensor surfaces of the elbows and knees, shins, wrists, hips) or else in typical sites for blows to the body (scalp above the “hatband line”), eyes, mouth, ears, chest, back, buttocks, back of the legs, extensor surfaces of the forearms [self-defense injuries], dorsum of the hand).

These rules of thumb need not always apply exactly, as each case must be examined individually. For example, a monocle hematoma is usually produced by a powerful blow from the front, such as a punch in the eye; there are rare cases, however, in which an appropriately sized child can inflict the same injury on himself or herself by running into a doorknob. One should not attempt to judge the recency of bruises from their color alone, as there is no evidence that this can be done reliably (10).

Fractures of differing ages (callus forms 8 to 12 days after a fracture) and unexplained fractures are strong indicators of child abuse (Box 3gifppt). They are seen in children under 18 months of age in 80% of cases, while accidental fractures are seen in children over 5 years of age in 85% of cases. Three or more fractures are found in 60% of cases of abuse, while 80% of accidental fractures are singular. About 40% of the fractures are of types that are unusual in clinical practice (5).

Thermal injuries
Scalds and, less commonly, burns are seen in 10% to 15% of abused children (13).

Scalds
About 10% to 25% of all scald injuries (i.e., injuries due to the effect of hot liquids) in small children are said to be of non-accidental origin. Scalds due to child abuse often appear in a symmetrical stocking or glove pattern on the feet and ankles or the hands and forearms, and are sharply demarcated (the so-called water level mark in immersion injuries) (14,15).

Burns
Burns (injuries from the application of dry heat) caused by child abuse are usually contact burns (direct application of hot objects: electrical appliances, cigarettes [Figure 2jpgppt], hot chipped wood, etc.). The commonly involved areas are the shoulders, back, forearms, back of the hand, and buttocks. Accidental burns are more often seen on the palms and on the palmar surfaces of the fingers (15).

Shaking trauma syndrome
Shaking trauma syndrome (STS), also called shaken baby syndrome (SBS), is a syndrome of traumatic injury consisting of subdural hematoma, retinal hemorrhages, and severe, diffuse brain injury, leading to the immediate appearance of neurological abnormalities (irritability, excessive sleep, vomiting, muscular hypotonia, somnolence, apathy, coma, epileptic seizures) (16–20). External injury is typically absent. Depending on where the abuser gripped the child, there may also be paravertebral serial rib fractures or metaphyseal fractures of the humerus or femur. In addition to the whiplash mechanism (formerly referred to as “whiplash shaken infant syndrome” [20, e4, e5]), rotational and shearing forces play a major role in generating this type of injury. There are frontal and occipital brain contusions as well as tears and avulsions of the bridging veins, often in proximity to the interhemispheric fissure (Figure 3a, b, and cgifppt). The presence of a hemorrhagic cortical infarct indicates a repeated event, because the prerequisite for this finding is prior cortical venous thrombosis.

Some of the affected children (usually infants) only reach the hospital in severely obtunded condition because of status epilepticus, with central respiratory disturbances and partial absence of the brainstem reflexes (pupillary light reflex, corneal reflex, cough reflex). In less severe cases, many different types of neurological damage might arise, with the associated long-term consequences (5,e4,e5). Cerebrovascular dysautoregulation, microinfarcts, ischemia, hypoxia, and brain edema can ensue. According to the literature, shaking trauma is fatal in 12% to 20% of cases; 5% to 10% of the victims remain in a vegetative state, 30% to 40% are blind or visually impaired in one eye or both, 30% to 50% suffer from spastic paralysis or marked motor developmental retardation, and 30% develop epileptic seizures (5,7,8,9,e5).

Funduscopy must be performed whenever shaking trauma is suspected. Further diagnostic studies include magnetic resonance imaging, computerized tomography, ultrasonography of the head, skeletal x-ray screening, and the following laboratory tests: urin-alysis, complete blood count, GOT, GPT, amylase, lipase, coagulation studies (Quick test and PTT), von Willebrand antigen and cofactor, fibrinogen, AT III, D-dimers, and PFA 100. A diagnostic lumbar puncture should not be performed.

Münchhausen syndrome by proxy (MSBP)
Münchhausen syndrome by proxy (MSBP) is a disorder with four distinguishing characteristics (5,22,e6):

•A child is taken to the doctor with disease manifestations that have been fabricated or deliberately induced by a person caring for the child, usually the mother.
•The child is taken repeatedly to different doctors, with excessive diagnostic testing and therapeutic interventions as the result.
•The person caring for the child denies knowledge of the true causes of the child’s disease manifestations.
•The medically inexplicable symptoms and signs resolve when the child is separated from the responsible individual (usually the mother).

Symptoms can be induced, for example, by the administration of foreign substances (deliberate intoxication; for forensic certainty, a toxicological analysis should be performed), or else existing disease manifestations can be exaggerated, or both. The responsible mother often appears to be intensely worried. In the literature, three different clinical constellations are described, with partial overlap between them:

•The active generation of injuries and administration of substances (“active inducers”).
•Presentation of the child to many different doctors, sometimes with variation in the alleged symptoms (“doctor addicts”).
•Mothers whose primary motive in seeking medical attention is to receive attention, care, and help for themselves in their current situation, rather than for the child (“help seekers”) (e7).

The incidence of MSBP is estimated at 2.5 cases per 100 000 children in the first year of life. It is said to be fatal in 6% to 33% of cases; one manifestation of MBSP, for example, is asphyxiation of an infant under soft bedcovers, which can be initially mistakenly diagnosed as sudden infant death syndrome (SIDS). MSBP is probably underdiagnosed in Germany (5,7,12). For further aspects, seeBox 4 (gifppt).

Child neglect
Physical neglect is defined as inadequate general care and inadequate health care, which can lead to massive developmental disturbances up to and including psychosocial short stature and, rarely, death by starvation (23,e8,24).

The child’s height and weight should be compared with the normal values for age and with the expected values in view of the child’s genetic family background. This comprises an assessment of the child’s nutritional status, with potential evidence for malnutrition. The diagnostic evaluation should generally be performed on an inpatient basis. In extreme cases of death by starvation, the child is often found, at the end, to have additionally suffered from severe dehydration or an intercurrent infection, such as pneumonia or an ascending urinary tract infection.

Emotional neglect and early childhood deprivation are the potentially most severe risk factors for impaired emotional or intellectual development and are also found as cofactors in most cases of other types of child maltreatment. They are characterized by lack of recognition of the child’s developmental needs and by the lack of a normal parent–child interaction. The child suffers either from quantitatively inadequate emotional support, or else from only weak support, delivered by constantly changing individuals (25,e9).

Documentation and the obtaining of evidence
Child abuse and neglect must be meticulously documented, particularly in cases where neither the Child Protection Office nor the police are immediately informed. Alongside the photographic documentation of visible injuries (with a scale on the picture; digital photographs are acceptable), the use of preprinted documentation forms is also recommended. Documentation sheets can also be downloaded from the Internet at www.kindesmisshandlung.de. The obtained history and the examiner’s own physical findings should be put down in writing with an indication of the date and time; the same holds for all obtained tissue samples (urine, blood, hair, other [biological] samples, swabs) and for other pieces of evidence taken from the patient (foreign deposited substances of a biological nature, clothing samples, etc.).

Mental health consequences
Child abuse and (sexual) traumatization have long-lasting effects on mental health: a wide variety of cognitive and emotional disturbances, later problems with drug and alcohol abuse, risky (disinhibited) sexual behavior, a tendency to overweight, and criminality both in childhood and in adulthood. Corresponding preventive and therapeutic strategies are urgently necessary.

Interventions
Different types of intervention are indicated depending on the degree of suspicion, the circumstances of the child’s presentation, and the type of abuse. Vague suspicions that arise during a consultation in a doctor’s office require a different intervention concept from obvious, severe abuse leading to emergency hospitalization; sexual abuse must be handled differently from Münchhausen’s syndrome by proxy. In general, child protection requires the cooperation of persons from many different professions, as well as knowledge of the locally/regionally available child protection resources and personnel. Hospitals are well advised to establish child protection committees, as has been done in Switzerland and Austria. Whenever the suspicion of child abuse or neglect arises, all potential responses should be considered, ranging from a conversation with the custodial parents, relatives, and other persons from the child’s social circle (e.g., the family physician, the grandparents) all the way to notification of the Child Protection Office or the police in cases of severe abuse or the suspicion of sexual abuse (for the relevant medicolegal considerations, see below). If the facts of the case are unclear, forensic medical consultation is recommended, combined with appropriate documentation, so that evidence can be presented in a judicial setting (civil, family, or criminal court).

When the suspicion of child maltreatment is well documented in this way, the physician need have no fear of legal consequences resulting from the violation of medical confidentiality. The physician is at greater risk of incurring negative consequences (including self-reproach) for himself or herself by failing to follow up a suspicion of child maltreatment; this can lead to further maltreatment, often more severe than it was at first. Another possible option is to describe the facts of the case anonymously to the Child Protection Office or family court, together with a request for a recommendation about how to proceed and information about the types of aid that the law provides in such cases. This procedure, and the decision ultimately taken, should also be well documented. If further objects or pieces of evidence other than the documented medical findings should come into the possession of the physician or the hospital (e.g., articles of clothing with biological deposits on them, such as blood, saliva, secretions, etc.), these should be safely secured, so as to preserve the chain of evidence for judicial purposes.

Legal matters
The right of parents to care for their children is grounded in the German Constitutions’s protection of marriage and the family (Art. 6 GG), which the “commonality of state institutions” has the duty to protect (Art. 6 Para. 2 Item 2 GG). The German Civil Code (Bürgerliches Gesetzbuch, BGB), § 1631 Para. 2, contains the following statement regarding the exercise of parental custodial rights under family law:

(2) Children have the right to be raised without violence. Corporal punishments, psychological injuries, and other degrading child-raising measures are forbidden.

State institutions such as the Child Protection Offices should, and must, provide help and intervene if necessary, and the family court is entitled to take appropriate measures if the well-being of a child is endangered (§ 1666 BGB). The police can also be involved, although this is not required by law. In 2005, in the wake of a number of spectacular cases of fatal child abuse, § 8a SGB VIII was introduced into the German Social Law Code (Sozialgesetzbuch, SGB); this enactment gives concrete form to the state’s duty to protect children, requiring Youth Departments (Jugendämter) to assess the extent of endangerment to childrens’ well-being. As is stated in § 8a Para. 1 Item 1 SGB VIII:

“If the Youth Department becomes aware of weighty reasons to suspect the endangerment of a child’s well-being, it is obliged to assess the risk of endangerment through a collaboration of specially trained personnel from multiple disciplines […].”

There is no official duty to report cases of child maltreatment and neglect in Germany, yet the legal position of a physician with respect to an endangered child is that of a guarantor or protector. Thus, physicians have a higher duty than laypersons to take action against the endangerment of a child’s well-being. Physicians have the duty to maintain confidentiality (§ 203 StGB, § 9 MBO-Ä), as do persons who assist physicians in the exercise of their profession (§ 203 Para. 3 Item 1 StGB). If, however, a physician withholds confidential information from the authorities, and further crimes are committed thereafter, a complaint against the physician may arise. Thus, the reasons for maintaining confidentiality, as well as the arguments for violating it, should always be meticulously documented. Information that a physician is ordinarily required to keep confidential may legally be disclosed if a situation of “justifying emergency” (rechtfertigender Notstand) prevails (§ 34 StGB). In case of judicial proceedings against a person suspected of abusing or neglecting a child, the treating physicians can be summoned to appear before the court as expert witnesses or as an official expert.

Conclusion
An interdisciplinary effort is needed among all the institutions sharing responsibility for child protection so that the problem of violence against children can be effectively addressed and the number and severity of cases can be reduced. Medical students and nurses need to be better trained in the subject, and physicians in the relevant specialties—general medicine, pediatrics, and trauma surgery—need to receive improved specialized training. In 2005, in the light of these pressing needs, the American Board of Pediatrics introduced the concept of the “child abuse pediatrician,” stating that there should be one specialist of this type per 1 million population, and one in every academic faculty of medicine (e10). Whenever a pediatrician voices a suspicion of child maltreatment, a forensic medical consultation should follow. Parental involvement is desirable; a psychologist should be consulted as well, and there should be a discussion with the family physician and also, whenever appropriate, with the Youth Department and/or the police. The physician’s duty to maintain the confidentiality of medical information need not stand in the way of these proceedings.

Conflict of interest statement
The authors declare that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.

Manuscript submitted on 14 August 2009, revised version accepted on 27 January 2010.

Translated from the original German by Ethan Taub, M.D.


Corresponding author
Prof. Dr. med. jur. Reinhard Dettmeyer
Institut für Rechtsmedizin der Justus-Liebig-Universität Gießen
Frankfurter Str. 58
35392 Gießen, Germany
Reinhard.Dettmeyer@forens.med.uni-giessen.de

@For e-references please refer to:
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Child Abuse and Neglect