THIRD EDITION

G.W. Medical Publishing, Inc. St. Louis THIRD EDITION

Angelo P. Giardino, MD, PhD, FAAP Associate Chair – Pediatrics Associate Physician-in-Chief/Vice President, Clinical Affairs St. Christopher’s Hospital for Children Professor in Pediatrics Drexel University College of Medicine Adjunct Professor of Pediatric Nursing LaSalle University School of Nursing Philadelphia, Pennsylvania

Randell Alexander, MD, PhD, FAAP Professor of Pediatrics, and Chief Division of Child Protection and Forensic Pediatrics Department of Pediatrics University of Florida Jacksonville, Florida Professor of Pediatrics Morehouse School of Medicine Atlanta, Georgia

G.W. Medical Publishing, Inc. St. Louis FOREWORD Safeguarding the health and well-being of all children has been an increasing focus of modern society. We have come far from the days when parents considered their children “property.” Along the way we have instituted many measures to improve the health of children: immunizations, car seats, lead detection and abatement, the “Back to Sleep” campaign, and the “Reach Out and Read” campaign, to name a few. The battle against child abuse and neglect has also made significant strides, although the war is far from over. Twenty years ago our knowledge of normal anogenital anatomy in children was just beginning to emerge, and disclosures about child sexual abuse were often discounted as stories confabulated by children. Secrets about being molested remain hidden in many cases, but sometimes they do surface in the psychiatric and medical complaints of adult men and women. It is hoped that research as well as professional and lay educational efforts have lessened the disease burden of many sexually abused individuals. Although the various behaviors—shaking an infant, sexual abuse, neglect, etc— involved in child maltreatment are clearly detrimental to children, the mechanisms and supporting evidence required for proof are not always clearly established. For example, simple mathematical models using basic principles of physics do not sufficiently capture the unique properties of the brain. Efforts are being made to create a more precise biomechanical model to simulate an infant’s head and brain during a shaking episode. Additionally, early articles not substantiated by subsequent data sometimes resurface during courtroom testimony. Experts must remain cogni- zant of the changing literature and information on child maltreatment. There is also the abundance of “experts” who ascribe to faulty and unsubstantiated information. In response, the child abuse community has been moving toward a certification process by the American Board of Pediatrics. Such a process would minimize the opportunity for self-proclaimed experts to contradict legitimate evaluations and testimony. The challenges that face those who seek to protect children from maltreatment include moving forward, preventing abuse before it starts, and reducing the rate of recidivism in those who have been abused. Professional education and early identification are critical to secondary prevention. Appropriate judicial decisions are also essential to ensure that children are not inappropriately returned to parents who lack the necessary skills to care for their offspring. Interventional programs must be created to make reunification a safe and satisfactory experience for children and their parents. Primary prevention is perhaps even more complicated. Although epidemi- ological studies have identified high-risk factors for abuse, providing anticipatory interventional services is costly and only partially validated. The societal issues of poverty, violence, and substance abuse are clearly contributing factors. As professionals committed to helping children reach their potential, we must take steps to ensure that all children are cared for in a safe, nurturing environment. Fortu- nately many promising programs are on the horizon, such as the Health CARES (Child Abuse Recognition and Evaluation Study) Network and the efforts of the Centers for Disease Control and Prevention (CDC) toward child abuse prevention. Up-to-date, evidence-based literature plays a vital role in the educational process. Child Maltreatment: A Clinical Guide and Reference and A Comprehensive Photographic Reference Identifying Potential Child Abuse, 3rd Edition, with its wealth of information compiled by multiple childcare professionals who work individually and collectively to prevent, identify, evaluate, and treat children and families facing the many chal- lenges associated with a high risk of child maltreatment, is part of this process. The more we learn, the stronger our ability is to effectively keep children safe. Our resolve remains strong to work tirelessly to reduce and eventually remove the threat posed to the well-being of all children by child maltreatment. With education, sound

xi Foreword

information such as that contained in this textbook, research, and advocacy, we can work individually and collectively to influence the future of the most vulnerable members of our society.

Carol Berkowitz, MD, FAAP Executive Vice Chair Department of Pediatrics Harbor-UCLA Medical Center Professor of Clinical Pediatrics David Geffen School of Medicine at UCLA Torrance, CA

xii FOREWORD The field of child maltreatment has evolved over a period of many decades. Over the years, the developments have been both heartening and discouraging. Greater attention has been paid to the problem and accompanying issues, raising hope that the epidemic of child abuse can be erradicated. However, as we continue to learn about child maltreatment we see more cases come to light, discouraging the efforts of the individual professionals handling them. Child maltreatment was once a clandestine topic that was not discussed. Society as a whole viewed it as a problem that did not exist in wealthy or elite families. Often only medical professionals were privy to this family secret and reporting was sporadic. As we have come to know more about the problem we find that it crosses all economic, cultural, social, and racial lines. Any family could harbor some form of child maltreatment, yet appear perfectly normal to the community. It is encouraging to see how many disciplines, including medical, law enforcement, legal, and social science professionals, are now included in the comprehensive approach to child maltreatment. Each specialty has much to contribute as they interact with families. Their efforts are valuable not only in handling the results of child maltreatment, but also in preventing the development of patterns of child maltreatment within the family unit. Although the medical community is still the primary detection unit, a variety of professionals must be informed and trained to deal with child maltreatment in its many forms. With resources such as this comprehensive volume on child mal- treatment, professionals are better equipped to deal with children who have been abused, perpetrators, families in crisis, and individuals who are involved in the pro- cess of handling child maltreatment cases. Better dialogue between disciplines is encouraged, as collaboration and cooperation between the disciplines permits all professionals to do their best in addressing maltreatment issues. The goal is to help children and their families. The first priority is the protection of the child, which is optimally achieved through preventive efforts. This book has ample coverage of the role each professional and caregiver plays in protecting children from abuse. Prevention efforts involve the entire community and are both focused and general in nature. Families and children at particular risk are targeted earlier in many cases. Supportive services for families are becoming more widespread as the impact of child maltreatment has become recognized. This book offers practical advice on how such preventive efforts can be implemented. For cases where child maltreatment has taken place, specific medical care is outlined, with special attention given to dealing with parents who are also perpetrators. The roles of medical professionals cannot be overemphasized since the vast majority of child maltreatment cases are seen in the ER or at a primary healthcare provider’s office. Careful approaches are offered to teach medical professionals how to maintain evidence that may be crucial to law enforcement personnel while treating the child. The importance of the crime scene is explained, along with the sources of both obvious and less-than-obvious clues as to what has happened. The function of social services personnel who are at hospitals and clinics is described so that this valuable resource is not overlooked. When first responders at a scene discover evidence of child maltreatment or neglect, the approach differs somewhat from cases discovered by medical personnel. The steps that are taken are outlined clearly, with careful attention to building a foundation of evidence as well as seeking to protect the child. The balance of obtaining medical evidence and being sensitive to the needs of the child and family is explained, with practical approaches to achieving both evidentiary and humanitarian goals. A concise presentation of what happens when the court system becomes involved is also offered.

xiii Foreword

The third edition of Child Maltreatment: A Clinical Guide and Reference and A Comprehensive Photographic Reference Identifying Potential Child Abuse presents a contemporary, complete, and balanced look at the epidemic of child maltreatment and what is being done to combat it. The desired outcome is healthier, happier children who grow to become well-adjusted adults and are readily integrated into society as contributing members. Through the comprehensive approach offered in this textbook it is hoped that we are getting closer to this goal.

David Chadwick, MD, PhD Director Emeritus The Chadwick Center Children’s Hospital, San Diego, California Research Professor Department of Pediatrics University of Utah

xiv PREFACE Child maltreatment in its various forms remains a significant problem confronting children and their families worldwide. The incidence and prevalence statistics surrounding child maltreatment continue to be staggering when compared to the reduction in pediatric morbidity and mortality associated with infectious diseases over the past 100 years. This reference is put forth to help healthcare professionals, social service providers, and law enforcement personnel meet the challenges that arise in dealing with this preventable problem that harms children and their families. Although the text is approached primarily from a healthcare point of view, the information contained will also benefit other disciplines and professionals such as social service workers, attorneys, law enforcement officers, state agencies, and others who might be involved with children of suspect child maltreatment. Collected in this third edition is information concerning the multidisciplinary team approach to physical abuse, sexual abuse, psychological abuse, and neglect that has evolved over the past 40 years from the work of dedicated professionals. The previous two editions of Child Maltreatment: A Clinical Guide and Reference, edited by James A. Monteleone, MD, were well-received by clinicians dealing with abused and neglected children and serve as a solid foundation on which this nearly total revision is based. As the new editors, we have recruited 70 new contributing authors to add their expertise. The text has expanded from 28 chapters in the second edition to the current 43 contained in this volume. Since no one person or discipline could effectively address all aspects of child maltreatment, we sought specific expertise in each area and found dedicated colleagues who were willing to share their time and knowledge for this project. The contributing authors are all individuals who have been extensively involved in issues related to child health and protection activities for significant periods of time and are uniformly acknowledged as leading figures in their fields by peers and colleagues. In addition to the traditional chapters one would expect in a comprehensive text dealing with child maltreatment, such as those dealing with the forms of mal- treatment as well as prevention, evaluation, and intervention, we have added chapters on the risk of the Internet to the safety of children, intimate partner violence and its relationship to child abuse, the risks that might be found in a faith-based setting, how to prepare a case for court, how to prepare to be an expert witness, the approach to physician and nurse education regarding child maltreatment, and research and federal funding opportunities in the United States. We have emphasized the multidisciplinary team approach to caring for children who are maltreated. Specialists in each area offer insights regarding approaches to identifying and managing specific forms of child maltreatment, including procedures for evaluation and practical guidelines for handling cases. The companion volume to this book, Child Maltreatment: A Comprehensive Photo- graphic Reference Identifying Potential Child Abuse, has also been expanded with the addition of over 850 new photographs. The format has been revised from the previous editions and, where available, descriptions of the cases being illustrated have been added. Together, these two references present a comprehensive source of in- formation covering all areas of child maltreatment. It is hoped that with the addition of new chapters and the expansion of existing material, the clinician who deals with any area of child maltreatment will be more fully equipped to assess any situation appropriately and determine the best course of action. Information is a vital ally in recognizing the signs of maltreatment. A thorough clinical examination, interviews with the child and family, and possible site investigations depending on the situation, are critical. Differentiating maltreatment from other patterns of injury helps in the prosecution of the guilty and the protection of innocent caregivers. Clinicians must rely on the best evidence available at the time

xv Preface

of the child’s evaluation. Ultimately, all professionals have the shared goal of pre- venting child maltreatment, and as we move into the next phase of study of child maltreatment, we hope the effective techniques and programs described in the chapter on prevention will take hold and reduce the incidence and prevalence of child maltreatment worldwide. The focus of all our work is the health and well-being of children and their families, and we offer this volume as a powerful tool to use in creating a better future for them.

Angelo P. Giardino, MD, PhD, FAAP Philadelphia, PA Randell Alexander, MD, PhD, FAAP Atlanta, GA

xvi REVIEWS OF THE THIRD EDITION Whether in an intensive care unit caring Angelo Giardino and his interdisciplinary This 3rd edition of Child Maltreatment for a child abuse victim, providing train- team of colleagues have continued to includes the very latest in research and ing, or testifying as an expert witness, there improve on an already exceptional col- clinical issues related to the injury and is one resource that I know I can cite as a lection of essays focused on the nature, exploitation of children. The editors have reliable reference, and that is Child extent and seriousness of child maltreat- gathered the best and the brightest authors Maltreatment. This is the most outstand- ment in the United States and other in the field to write the chapters and the ing text of its kind, and provides a economically advanced countries. In volumes contain essential knowledge for complete review with relevant references on addition to providing the reader with a students and clinicians. It is designed to be all aspects of the medical diagnosis and deep understanding of the complex forces a reference and resource for all agencies treatment of child abuse and neglect. I that contribute to child maltreatment, the that assist and manage child recommend Child Maltreatment to all volume’s chapters offer clinicians and policy maltreatment issues. members of an investigative multidiscipli- makers alike state-of-the-art guidance in nary team and consider it a mandatory preventing and caring for children who Ann Wolbert Burgess, RN, DNSc, CS resource in any medical, social science, or become victims of abuse and neglect. Dr. Boston College Connell School of criminal justice library. Giardino and his colleagues are to be Nursing Sharon Cooper, MD, FAAP congratulated for their pioneering Adjunct Associate Professor of Pediatrics contributions in helping to halt the current University of North Carolina School of epidemic of child maltreatment cases. The third edition of this vital reference Medicine Richard J. Estes, DSW, ACSW designed for child maltreatment profes- Chapel Hill, North Carolina Professor sionals contains new, cutting-edge, and Clinical Assistant Professor of Pediatrics Chair, Concentration in Social and evidence-based information. Comprised of Uniformed Services University of Health Economic Development 2 volumes with a total of 62 chapters, Sciences Director, International Programs Child Maltreatment: A Clinical Guide Bethesda, Maryland University of Pennsylvania School of and Reference and A Comprehensive Chief, Developmental Pediatric Service Social Work Photographic Reference Identifying Womack Army Medical Center Philadelphia, Pennsylvania Potential Child Abuse covers virtually Fort Bragg, North Carolina every aspect of child physical, sexual, and psychological abuse, child neglect, and This edition of Child Maltreatment service delivery systems that either This publication presents a comprehensive builds on the terrific start provided by look at the issues involved in cases of child encounter or address child maltreatment. James Monteleone with an expansion This reference work should be in the maltreatment, emphasizing the contem- that is up-to-date, complete, and provides porary importance of this subject together library of every professional concerned the best available information from an with the problem of child maltreatment. with reviewing the multidisciplinary extraordinary group of contributors. It is techniques for forensically detecting as well a “must,” not only for specialists in the Kathleen Coulborn Faller, PhD, ACSW as addressing the needs of victims of such field of child abuse and neglect, but for maltreatment. The text provides profes- Professor, School of Social Work all health professionals who provide care Director, Family Assessment Clinic sionals in the fields of law, social science to children. and the healthcare industry with invalu- University of Michigan able source materials when confronted Richard Krugman, MD Ann Arbor, Michigan with suspected child maltreatment. Dean of Medicine Faye Battiste-Otto, RN, SANE University of Colorado School of President, American Forensic Nurses Medicine Palm Springs, California Denver, Colorado

xvii Contents

CONTENTS IN BRIEF

PHYSICAL MALTREATMENT CHAPTER 1: OVERVIEW OF CHILD MALTREATMENT . . . . . 1 CHAPTER 2: SKELETAL AND VISCERAL RADIOLOGICAL IMAGING 13 CHAPTER 3: HEAD INJURY ...... 37 CHAPTER 4: BRUISES AND BURNS IN CHILD MALTREATMENT . 63 CHAPTER 5: OPHTHALMIC MANIFESTATIONS ...... 83 CHAPTER 6: ORAL INJURIES ...... 91 CHAPTER 7: THORACOABDOMINAL INJURIES ...... 103 CHAPTER 8: THE CHEMICALLY ABUSED CHILD ...... 113

NEGLECT CHAPTER 9: NEGLECT AND ABANDONMENT ...... 153 CHAPTER 10: FAILURE TO THRIVE: A RECONCEPTUALIZATION . 195

SEXUAL MALTREATMENT CHAPTER 11: SEXUAL ABUSE: OVERVIEW ...... 209 CHAPTER 12: SEXUAL ABUSE: ISSUES RELATED TO INTERVIEWING CHILDREN ...... 227 CHAPTER 13: SEXUAL ABUSE: THE MEDICAL EXAMINATION . . 253 CHAPTER 14: SEXUALLY TRANSMITTED DISEASES ...... 289

PSYCHOLOGICAL MALTREATMENT & DEVELOPMENTAL HEALTH ISSUES CHAPTER 15: PSYCHOLOGICAL MALTREATMENT ...... 315 CHAPTER 16: DEVELOPMENTAL ASPECTS OF THE YOUNG CHILD 343 CHAPTER 17: PSYCHOPATHOLOGY AND THE ROLE OF THE CHILD PSYCHIATRIST ...... 367 CHAPTER 18: MUNCHAUSEN SYNDROME BY PROXY . . . . . 395 CHAPTER 19: PSYCHOLOGICAL ASSESSMENT AND TREATMENT APPROACHES ...... 409 CHAPTER 20: USING DRAWING IN SHORT-TERM ASSESSMENT AND INVESTIGATION ...... 449 CHAPTER 21: ROLE OF THE SCHOOL ...... 467

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CULTURES AT RISK OF CHILD MALTREATMENT CHAPTER 22: RISK OF THE INTERNET ...... 505 CHAPTER 23: RISK OF ABUSE IN FAITH COMMUNITIES . . . . 539 CHAPTER 24: CULTURAL ASPECTS ...... 557 CHAPTER 25: CHILDREN WITH SPECIAL NEEDS ...... 573 CHAPTER 26: FOSTER CARE: HEALTHCARE ISSUES . . . . . 595 CHAPTER 27: FAMILY ABDUCTION ...... 609 CHAPTER 28: PEDIATRIC SCREENING FOR INTIMATE PARTNER VIOLENCE ...... 625 CHAPTER 29: INTERPERSONAL VIOLENCE ...... 639

LEGAL ASPECTS AND FORENSIC ISSUES CHAPTER 30: THE ROLE OF LAW ENFORCEMENT IN THE INVESTIGATION OF CHILD MALTREATMENT ...... 659 CHAPTER 31: LEGAL ISSUES ...... 707 CHAPTER 32: PREPARING A CASE FOR COURT ...... 723 CHAPTER 33: PREPARING TO GIVE EXPERT TESTIMONY . . . . 761 CHAPTER 34: ROLE OF THE MEDICAL EXAMINER IN FATAL CASES 773 CHAPTER 35: CHILD FATALITY REVIEW TEAM ...... 805 CHAPTER 36: FORENSIC EVIDENCE COLLECTION ...... 853 CHAPTER 37: DNA EVIDENCE ...... 861

PROFESSIONAL ROLES IN INVESTIGATION, TREATMENT, & PREVENTION CHAPTER 38: MULTIDISCIPLINARY TEAMS ...... 917 CHAPTER 39: ROLE OF PHYSICIAN AND NURSE EDUCATION . . 935 CHAPTER 40: OPPORTUNITIES FOR FEDERAL FUNDING AND COLLABORATION: THE NATIONAL INSTITUTES OF HEALTH CHILD ABUSE AND NEGLECT WORKING GROUP ...... 979 CHAPTER 41: PUBLIC CHILD WELFARE: A HISTORY OF CHALLENGE AND OPPORTUNITY ...... 1003 CHAPTER 42: ROLE OF THE SOCIAL WORKER ...... 1031 CHAPTER 43: PREVENTION ...... 1063

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CHAPTER 1: OVERVIEW OF CHILD MALTREATMENT Definitions and Epidemiology ...... 1 Major Changes in Responding to Child Maltreatment ...... 3 Child Maltreatment as a Broader Term ...... 3 Understanding the Etiology of Child Maltreatment ...... 3 The Mandated Reporter ...... 4 The Role of Child Protective Services ...... 4 Collaborative Investigations ...... 5 Obtaining Information From Children...... 5 Attention to Prevention ...... 6 A Marked Increase in Research ...... 7 The Consequences Extend Into Adult Life...... 8 References ...... 8

CHAPTER 2: SKELETAL AND VISCERAL RADIOLOGICAL IMAGING Modalities ...... 14 Diagnostic Radiographs ...... 14 Nuclear Medicine...... 14 Computed Tomography ...... 15 Magnetic Resonance Imaging ...... 15 Ultrasound ...... 16 Musculoskeletal Injuries...... 16 Types of Fractures/Mechanisms of Injury ...... 16 Extremities ...... 17 Multiple Fractures ...... 18 Dating Skeletal Injury ...... 18 Regional Skeletal Injuries ...... 19 Femur ...... 19 Tibia and Fibula ...... 19 Foot Fractures ...... 19 Humeral Shaft Fractures ...... 19 Hands ...... 20 Spine Injuries ...... 20 Clavicle ...... 21 Sternum...... 21 Pelvis...... 21 Bony Thoracic Trauma ...... 22 Craniofacial Injuries ...... 23 Subdural Hematomas ...... 23 Epidural Hematomas...... 24 Subarachnoid Hemorrhages ...... 24 Intracranial Hemorrhages...... 25 Cerebral Edema ...... 25 Chronic Sequelae ...... 26 Skull Fractures ...... 26

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Maxillofacial Injuries ...... 26 Neuroimaging...... 27 Abdominal Injuries ...... 27 Liver ...... 28 Spleen ...... 28 Pancreas...... 28 Kidney ...... 29 Bladder and Urethra ...... 29 Esophagus ...... 29 Stomach...... 29 Duodenum ...... 29 Colon30 Differential Considerations in Child Abuse ...... 30 Conclusion ...... 33 References ...... 33

CHAPTER 3: HEAD INJURY Blunt Impact Head Injury ...... 38 External Craniofacial Injury...... 38 Skull Fractures ...... 39 Epidural Hemorrhage ...... 40 Rotational Head Injury and Shaken Baby Syndrome ...... 40 Mechanism of Injury ...... 40 Presentation...... 42 Retinal Hemorrhages ...... 43 Description ...... 43 Mechanism...... 43 Differential Diagnosis ...... 43 Associated Injuries in Inflicted Head Trauma ...... 44 Diagnostic Imaging ...... 45 Computed Tomography ...... 45 Magnetic Resonance Imaging ...... 45 Intracranial Injury ...... 45 Subdural Hemorrhage...... 46 Diffuse Axonal Injury ...... 46 Primary Versus Secondary Injuries ...... 47 Cervical Injury ...... 48 Timing of Injury ...... 48 Summary ...... 49 Perpetrators ...... 49 Differential Diagnosis...... 49 Accidents ...... 49 Falls ...... 50 Bleeding Disorders ...... 52 Metabolic Disorder ...... 52 Birth Injury...... 52 Intracranial Pathology ...... 52 Unique Theories of Causation ...... 53 Rebleeding ...... 53 Second Impact ...... 53 Talk and Deteriorate or Die Syndrome ...... 53 Summary ...... 53 Outcomes ...... 54 Prevention...... 54 References ...... 56 xxii Contents in Detail

CHAPTER 4: BRUISES AND BURNS IN CHILD MALTREATMENT The Skin: An Organ That Protects the Body From Invasion ...... 63 The Bruise as a Manifestation of Tissue Injury ...... 64 What Happens to Childern Who Suffer From Physical Maltreatment? . . . 67 Cold Instruments That Are Used to Impact the Skin ...... 69 Marks That Reflect Internal Injury and Internal Marks That Reflect External Injury ...... 70 Inflicted Burns ...... 72 Types of Burns...... 72 Differential Diagnosis ...... 74 Diagnosis ...... 77 History ...... 77 Examination ...... 77 Prevention ...... 78 Conclusion ...... 78 References ...... 79

CHAPTER 5: OPHTHALMIC MANIFESTATIONS Eyelids and Periorbital Area ...... 83 Conjunctiva ...... 84 Cornea, Anterior Chamber, and Lens ...... 84 Retina ...... 85 Retinal Signs of Shaken Baby Syndrome ...... 85 Mechanisms of Injury in Shaken Baby Syndrome ...... 86 Terson’s Syndrome ...... 86 Purtscher’s Retinopathy ...... 87 Features in a Case Series of Shaken Baby Syndrome ...... 87 Conclusion ...... 87 References ...... 88

CHAPTER 6: ORAL INJURIES Injuries to Teeth ...... 91 Avulsion ...... 91 Luxation...... 92 Displacement ...... 92 Tooth Fractures...... 93 Abuse Injuries to Oral Soft Tissues...... 93 Gingiva...... 93 Labial and Lingual Frenula ...... 93 Lips ...... 94 Tongue ...... 94 Hard and Soft Palate ...... 94 Burns ...... 95 Oral Manifestations of Emotional Abuse ...... 95 Oral Injuries to Infants ...... 95 Child Abuse, Bite Marks, and Patterned Injury ...... 95 Armamentarium Selection ...... 97 Dental Implications of Child Neglect ...... 98 Dentistry’s Involvement in Preventing Child Abuse and Neglect . . . . . 99 References...... 101

CHAPTER 7: THORACOABDOMINAL INJURIES Epidemiology...... 103 Mechanisms and Patterns of Injury ...... 103 Thoracic Injuries ...... 104

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Abdominal Injuries ...... 105 Medical Evaluation ...... 106 Historical Information ...... 106 Detection of Injuries...... 107 Physical Examination ...... 107 Laboratory Evaluation ...... 108 Diagnostic Imaging...... 108 Conclusion ...... 110 References...... 110

CHAPTER 8: THE CHEMICALLY ABUSED CHILD Chapter Road Map ...... 113 Historical Awareness of Child Abuse ...... 113 Defining Terms ...... 114 Epidemiology...... 115 Intentional Abusive Ingestion ...... 117 Routes...... 117 Motives/Intent ...... 117 Caregiver Psychopathology...... 118 Facilitate Sexual Assault or Abuse ...... 121 Discipline...... 123 Behavior Modification ...... 123 Amusement ...... 124 Other Motives ...... 124 Ingested Substances ...... 124 Association of Abuse by Poisoning With Child Physical Abuse . . . . 124 Unintentional Nonabusive Ingestion ...... 124 Unintentional Ingestion ...... 132 Supervisory Neglect...... 132 Endangerment (Neglect of Environmental Safety) ...... 133 History of Present Illness ...... 135 Clinical Presentations: Toxidromes...... 136 Clinical Laboratory ...... 136 Hypoglycemia...... 136 Hyponatremia/Water Intoxication...... 140 Blood Urea Nitrogen/Creatinine ...... 141 Creatine Phosphokinase and Aldolase...... 141 Liver Enzymes ...... 141 Urine Analysis...... 141 Hypernatremia, Water Deprivation, and Salt Ingestion . . . . . 141 Osmolar Gap...... 142 Arterial Blood Gases ...... 142 Metabolic Acidosis and Anion Gap ...... 142 Fecal Analysis...... 144 Toxicology Laboratory ...... 144 Drugs of Abuse ...... 145 Toxicology Laboratory Reports...... 147 Detection Methods ...... 147 Radiographical Imaging ...... 147 Conclusion ...... 147 References...... 149

CHAPTER 9: NEGLECT AND ABANDONMENT Definition of Child Neglect ...... 153 Conceptual Model ...... 162 Incidence...... 163 xxiv Contents in Detail

Dynamics of Neglect ...... 165 Social Factors ...... 166 Maternal and Paternal Factors ...... 167 Child Factors ...... 168 Evaluation of Neglect in the Healthcare Setting ...... 168 Generic Screening ...... 169 Specific Screening...... 170 Types of Neglect...... 170 Medical Neglect ...... 170 History...... 172 Physical Examination ...... 172 Laboratory Findings ...... 172 Failure to Thrive...... 173 Physical Neglect ...... 173 History...... 173 Physical Examination ...... 174 Laboratory Findings ...... 174 Caregiver-Child Interaction...... 174 Abandonment ...... 174 Educational Neglect...... 176 Interventions...... 176 Generic Measures...... 177 Specific Measures ...... 178 Outcome of Neglect...... 180 Conclusion ...... 180 References ...... 181 Appendix 9-1: 2003 Child Abuse and Neglect State Statutes Series Ready Reference Reporting Laws: Religious Exemptions ...... 189 Alabama ...... 189 Alaska190 Arizona...... 190 California ...... 190 Colorado ...... 190 Connecticut ...... 190 Delaware ...... 190 District of Columbia...... 190 Florida...... 190 Georgia...... 191 Guam ...... 191 Idaho ...... 191 Illinois...... 191 Indiana...... 191 Iowa ...... 191 Kansas...... 191 Kentucky ...... 191 Louisiana ...... 191 Maine ...... 191 Michigan ...... 191 Minnesota ...... 192 Mississippi...... 192 Missouri ...... 192 Montanta...... 192 Nevada...... 192 New Hampshire...... 192 New Mexico ...... 192

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Ohio ...... 192 Oklahoma ...... 193 Pennsylvania ...... 193 Vermont ...... 193 Virginia ...... 193 Washington ...... 193 Wyoming...... 193

CHAPTER 10: FAILURE TO THRIVE: A RECONCEPTUALIZATION Risk Factors ...... 196 Poverty...... 196 Emotional Factors ...... 196 Other Parental Factors ...... 196 Children’s Factors...... 197 Etiology ...... 197 Evaluation and Diagnosis ...... 198 History ...... 198 Physical Examination ...... 199 Laboratory Evaluation ...... 200 Treatment ...... 201 Outcome ...... 203 Conclusion ...... 203 References ...... 203

CHAPTER 11: SEXUAL ABUSE: OVERVIEW The Epidemiology of Child Sexual Abuse ...... 209 Victim Risk Factors and Perpetrator Profiles ...... 210 The Disclosure Process ...... 211 Symptoms of Child Sexual Abuse ...... 212 Role of the Mental Health Provider ...... 213 Role of the Medical Provider ...... 213 False Allegations of Sexual Abuse and Custody Disputes ...... 216 The Impact of Sexual Abuse and Treatment ...... 217 Legal Issues and Reporting ...... 219 References ...... 221

CHAPTER 12: SEXUAL ABUSE: ISSUES RELATED TO INTERVIEWING CHILDREN Caregiver History ...... 230 Disclosure Process ...... 232 Developmental Considerations ...... 235 Emotional and Patient Comfort Issues ...... 237 Interview Models...... 238 Incorporating Interviewing Skills Into the Medical Evaluation of the Child . 239 Building Rapport ...... 239 Collecting Substantive Information ...... 241 Types of Questions ...... 242 Closure...... 247 Documentation ...... 246 Conclusion ...... 249 References ...... 249

CHAPTER 13. SEXUAL ABUSE: THE MEDICAL EXAMINATION Purpose of the Medical Examination in Alleged Child Sexual Abuse . . . 253 Preliminaries to Conducting an Examination ...... 253 xxvi Contents in Detail

Preliminary Evaluation Step One ...... 254 Preliminary Evaluation Step Two ...... 254 Indications for a Physical Examination ...... 256 Determining Need for an Immediate Examination ...... 256 Deferring the Examination ...... 257 Preparing the Child for a Physical Examination...... 257 Examination Positions and Techniques ...... 258 Review of Genital and Anal Anatomy...... 260 Vagina...... 260 Vaginal Vestibule ...... 261 Hymenal Membrane...... 261 Hymenal Orifice Diameter ...... 266 Anus ...... 268 Anal Anatomy ...... 268 Interpreting Residual Effects From Sexual Contact...... 270 Examining and Interpreting Anal Findings ...... 271 Male Genitalia ...... 271 Residual Effects From Sexual Contact: Patterns of Trauma ...... 272 Genital Fondling...... 272 Vulvar Coitus...... 273 Vaginal Penetration ...... 273 Accidental Injuries ...... 274 Labial Agglutination...... 274 Extragenital Trauma ...... 275 Sodomy and Genital-to-Anal Contact Without Penetration ...... 275 Interpretation of Healed and Healing Injuries ...... 276 Sexually Transmitted Disease ...... 278 Forensic Evidence ...... 278 Medical Conditions That Mimic Child Sexual Abuse ...... 278 The Medical Record and Diagonostic Conclusions...... 279 Documenting the Clinical Evaluation...... 280 The Medical Record: Overview ...... 280 Medical History Documentation ...... 280 Putting It All Together: Formulating a Diagnosis ...... 281 History of Sexual Abuse Without Diagnostic Evidence...... 282 Diagnostic Findings Supported by History ...... 282 Diagnostic Findings Without Support of History ...... 283 Confirmed Abuse Without Residual Signs ...... 283 Insufficient History and Diagnostic Findings ...... 283 Other Possible Scenarios...... 284 Summary of Cases ...... 284 Conclusion ...... 284 References ...... 284

CHAPTER 14: SEXUALLY TRANSMITTED DISEASES General Principles Regarding Sexually Transmitted Diseases in Abused Children...... 289 Bacterial Sexually Transmitted Diseases ...... 292 Gonorrhea ...... 292 Clinical Presentation ...... 292 Laboratory Diagnosis ...... 293 Treatment ...... 293 Chlamydia...... 293 Clinical Presentation ...... 295 Laboratory Diagnosis ...... 295

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Treatment ...... 295 Syphillis ...... 296 Clinical Presentation ...... 296 Laboratory Diagnosis ...... 296 Treatment ...... 297 Bacterial Vaginosis ...... 297 Clinical Presentation and Laboratory Diagnosis ...... 297 Treatment ...... 298 Trichomoniasis ...... 298 Clinical Presentation ...... 298 Laboratory Diagnosis ...... 298 Treatment ...... 298 Genital Mycoplasmas ...... 298 Other Uncommon Bacterial Sexually Transmitted Diseases . . . . . 299 Viral Sexually Transmitted Diseases ...... 299 Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome ...... 299 Clinical Presentation ...... 300 Laboratory Diagnosis ...... 301 Treatment ...... 301 Herpes Simplex Virus ...... 303 Clinical Presentation ...... 303 Laboratory Diagnosis ...... 304 Treatment ...... 304 Human Papillomavirus ...... 305 Clinical Presentation ...... 306 Treatment ...... 307 Hepatitis Viruses...... 308 Miscellaneous Sexually Transmitted Diseases and Conditions...... 309 References...... 310

CHAPTER 15: PSYCHOLOGICAL MALTREATMENT Definitional Issues ...... 316 Operational Definitions ...... 317 Cultural Issues...... 318 Prevalence ...... 321 Causes and Correlates ...... 321 Characteristics of Children and Parents ...... 321 Parental Shame and Violence ...... 322 Family and Relationship Dynamics ...... 323 Mental Illness...... 324 Substance Abuse ...... 325 Poor Parenting Skills and Modeling ...... 326 Socioeconomic Stress and Social Support...... 326 Consequences...... 327 Insecure Attachment Style ...... 327 Social and Cognitive Impairments ...... 328 Internalizing Problems ...... 329 Externalizing Problems ...... 329 Differential Effects Based on Age and Gender ...... 330 Prevention, Intervention, and Treatment ...... 331 Accurate Assessment of Psychological Maltreatment ...... 331 Counseling or Therapy for Individuals and Families ...... 331 Community-Based Intervention Programs ...... 332 xxviii Contents in Detail

Public Policy Efforts...... 333 Conclusion ...... 334 References ...... 334

CHAPTER 16: DEVELOPMENTAL ASPECTS OF THE YOUNG CHILD Normative Development ...... 343 The Nature of Development ...... 343 Development Is Jointly Influenced by Heredity and Environment . . 344 The Plasticity of Development ...... 344 The Continuity of Development ...... 344 Development in Different Domains Is Connected...... 344 Bidirectional Relationships ...... 344 Contexts of Development ...... 345 Developmental Milestones ...... 345 General Development ...... 345 Specific Developments ...... 349 Developmental Milestones and Maltreatment ...... 349 Maltreatment and Development: Areas for Consideration...... 349 Developmental Issues in the Investigation and Prosecution of Maltreatment Cases...... 350 Cognitive Development...... 350 Social Development...... 351 Language ...... 351 Social Context...... 352 Sexual Behavior in Children: Relationship to Maltreatment . . . . . 352 The Development of Sexual Behavior in Children ...... 353 Sexual Behaviors in Suspected Victims of Child Sexual Abuse . . . 353 Development of Children With Special Needs and Risk for Child Maltreatment ...... 354 Developmental Consequences of Maltreatment...... 356 Conclusion ...... 359 References ...... 359

CHAPTER 17: PSYCHOPATHOLOGY AND THE ROLE OF THE CHILD PSYCHIATRIST Psychopathology as the Result of Abuse ...... 367 Physical Maltreatment ...... 368 Psychiatric Disorders Associated With Physical Maltreatment and Neglect ...... 369 Emotional Maltreatment ...... 374 Sexual Maltreatment...... 374 Psychobiological Correlates of Maltreatment ...... 379 Interventions for Maltreated Children and Adolescents ...... 380 Psychotherapeutic Interventions ...... 380 Pharmacotherapy ...... 382 Prevention of Maltreatment...... 383 Role of the Child Psychiatrist ...... 384 References ...... 385

CHAPTER 18: MUNCHAUSEN SYNDROME BY PROXY Overview...... 395 Presentation and Epidemiology ...... 399 Victims...... 399 Perpetrators ...... 400 Conditions Created by MSBP Perpetrators ...... 401

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Warning Signs...... 402 Management of Suspected Cases ...... 403 References ...... 407

CHAPTER 19: PSYCHOLOGICAL ASSESSMENT AND TREATMENT APPROACHES Psychological Responses to Various Types of Abuse...... 410 Psychological Responses to Physical Maltreatment ...... 410 Psychological Responses to Emotional Maltreatment ...... 413 Psychological Responses to Sexual Abuse ...... 413 Psychological Variations in Response to Abuse and Maltreatment . . . 417 Psychological Treatment Approaches for the Maltreated Child . . . . . 418 The Validation Phase...... 418 Identification of Abuse ...... 418 Documentation ...... 419 Legal Issues ...... 420 The Treatment Planning Phase ...... 422 Individual Approaches ...... 422 Art and Nonverbal Approaches...... 422 Family/Group Approaches ...... 422 Play Therapy Approaches ...... 424 False Allegations of Abuse ...... 425 Psychological Assessment Strategies ...... 428 General Psychological Assessment Measures ...... 428 Specialized Assessment Tools ...... 429 Psychophysiological Assessment ...... 430 Additional Tools ...... 431 The Stabilization and Neutralization Phase ...... 432 Clinician Assessment of the Child’s Available Support System . . . 432 Psychological Validation of the Child...... 432 Dispelling the Psychological Element of Fear ...... 433 Assessing the Psychological Damage Resulting From the Abuse . . . 434 Psychologically Mending Self-Esteem ...... 434 Affirming Personal Body Integrity and the Right to Self-Protection . . . 436 Enhancing Verbal Expression and Resistance to Further Abuse . . . 437 Addressing Psychological Issues of Loss and Betrayal ...... 438 Family Issues and Follow-up Practices...... 439 References ...... 440

CHAPTER 20: USING DRAWING IN SHORT-TERM ASSESSMENT AND INVESTIGATION Drawings as Assessment Tools...... 449 Drawings as Treatment and Intervention ...... 450 Getting Started: Drawing Materials ...... 451 Normal Artistic Development...... 451 Indicators of Child Maltreatment and Trauma in Children’s Drawings . . . 452 Incorporating Drawing Into Treatment ...... 456 Establishing Rapport With Children Through Drawing ...... 456 Drawing Tasks for Trauma Debriefing and Intervention ...... 458 Trauma-Specific Questions ...... 459 Ending the Session ...... 460 Ethical Issues ...... 460 Confidentiality ...... 460 Ownership...... 461 xxx Contents in Detail

Drawings as Admissible Evidence ...... 462 Conclusion ...... 462 Resources for Additional Information...... 463 References ...... 463

CHAPTER 21: ROLE OF THE SCHOOL Who Reports? ...... 467 Contents of the Report ...... 467 Level of Proof Required to Report...... 468 Penalty for Not Reporting ...... 468 Immunity From Criminal Prosecution and Civil Liability...... 468 School Policies on Reporting ...... 468 Purpose of the Policy...... 468 Contents of the Policy ...... 469 Reporting Institutional Abuse ...... 470 Once a Report is Made ...... 471 Discipline in Schools ...... 471 False Allegations...... 473 Defense Against Abuse in School...... 473 Selection of Personnel ...... 473 Background Record Checks...... 474 Interviewing ...... 474 Reference Checks...... 475 Other Policy Considerations ...... 475 In-Service Training of Staff and Volunteers ...... 475 Screening Volunteers...... 476 Supervision of Volunteers ...... 476 Beyond the Legal Minimums ...... 476 Characteristics of Children With a History of Maltreatment ...... 478 Effects on Development...... 482 Sexual Abuse ...... 483 Conclusions ...... 483 Characteristics of the Teacher ...... 483 Strategies for Teachers ...... 484 Build a Sense of Trust ...... 484 Expect Success ...... 485 Teach Social Skills ...... 485 Teach Life Skills ...... 486 Teach Communication Skills ...... 486 Allow Students to Be Students...... 487 Teach Positive Coping Skills ...... 488 Provide Pleasant Experiences ...... 489 Build Self-Esteem...... 490 Improve Academic Skills ...... 490 Provide Avenues to Gain Insight ...... 491 Resiliency of Children ...... 491 Training and Support for All Educational Staff Members ...... 493 Conclusion ...... 493 Educational Neglect...... 494 Causes of Educational Neglect ...... 495 Neglecting the Child With Special Needs ...... 498 Consequences of Educational Neglect...... 499 Summary ...... 499 References ...... 499

xxxi Contents in Detail

CHAPTER 22: RISK OF THE INTERNET Risk to Children...... 510 Risks Associated With Using the Internet ...... 511 How Different Types of Offenders Use the Internet ...... 512 Collectors of Pornography ...... 512 Producers of Child Pornography ...... 513 Child Sexual Offenders ...... 514 Unsolicited Contact With Potential Predators ...... 517 Law Enforcement’s Reaction to the Use of the Internet ...... 519 Difficulties in Prosecution ...... 520 Producers of Child Pornography ...... 522 Individuals Who Use the Internet to Lure Victims ...... 523 How to Protect Children ...... 524 Preventive Strategies ...... 524 Conclusion ...... 527 References ...... 527 Appendix 22-1: Sample Affidavit...... 530 Supporting Affidavit ...... 530 Definitions...... 532 Appendix 22-2: Glossary of Internet and Online Terms ...... 535

CHAPTER 23: RISK OF ABUSE IN FAITH COMMUNITIES Overview of the Issue ...... 539 Increased Vulnerability ...... 541 Denial...... 542 Assumption of Safety and Trust ...... 542 Institutional Secrecy...... 543 Opportunity and Access to Vulnerable Children and Adults . . . . . 543 Discomfort With Sexuality ...... 543 Misuse or Misinterpretation of Sacred Texts ...... 544 Need for Safeguards...... 545 Education for Clergy and Congregation ...... 546 Protective Policies ...... 547 Adequate Screening of Staff and Volunteers ...... 547 Accountability and Supervision of Staff and Volunteers . . . . . 547 Consequences for Harmful Behavior ...... 548 Appropriate Response to Child Abuse Allegations ...... 548 Poor Self-Care by Religious Leaders ...... 548 Mandated Reporting Laws Not Nationally Consistent...... 549 Greater Difficulty Prosecuting Child Abuse Cases in Faith Communities . 550 Trends ...... 550 Development of Local Congregational Safeguards and Judicatory Policies and Resources ...... 550 Greater Understanding of Child Abuse as a Systemic Problem . . . . 551 Government Intervention ...... 551 Less Hesitancy to Sue Religious Bodies and Increased Prosecution of Religious Leaders ...... 551 Less Use of Spiritual Healing as a Legal Defense ...... 551 Future Research ...... 552 Estimating the Extent of Abuse by Religious Leaders and in Religious Settings ...... 552 Understanding the Risk in Non-Anglo and Non-Mainline Congregations ...... 552 Determining the Efficacy of Prevention Efforts ...... 552 Analyzing the Effect of the 2002 “Crisis” on Religious Life . . . . . 553 References ...... 553 xxxii Contents in Detail

CHAPTER 24: CULTURAL ASPECTS Definitions ...... 557 Cultures ...... 557 Child Maltreatment, Abuse, and Neglect ...... 557 Child Maltreatment, Culture, and Change ...... 558 Incidence/Prevalence...... 560 Making “Difference” Matter ...... 560 Culture, Race/Ethnicity, and Child Maltreatment ...... 560 Poverty, Social Capital, and Child Maltreatment ...... 562 Child Maltreatment and Domestic Violence ...... 563 Corporal Punishment in US Schools...... 564 Conflation of Structural Violence and Cultural Difference . . . . 564 Practices: Lessons From Anthropological and Cross-Cultural Study . . . . 565 On Cultural Competence ...... 568 References ...... 569

CHAPTER 25: CHILDREN WITH SPECIAL NEEDS Maltreatment of Children Who Have Disabilities ...... 573 Incidence/Prevalence ...... 573 Risk Factors ...... 574 Scope of Abuse of Children With Disabilities ...... 576 Neglect of Children With Disabilities ...... 577 Child Maltreatment as the Cause of Disability ...... 579 National Data Sets on Disability Caused by Maltreatment . . . . . 579 Damage to the Brain ...... 579 Other Types of Head Injury...... 580 Near Miss Drowning ...... 580 Asphyxiation ...... 580 Spinal Cord Injury ...... 580 Burns ...... 580 Fetal Exposure to Drugs and Alcohol...... 581 Domestic Violence ...... 581 Psychological Injury ...... 582 Firearm Injury...... 582 Munchausen Syndrome by Proxy ...... 582 Folk Medicine ...... 582 Neglect...... 583 Long-Term Sequelae ...... 583 The Cause and Effect Relationship ...... 583 The Social Context of Abuse and Disability ...... 584 Public Policy ...... 584 Global Trends in Child Maltreatment ...... 585 Conclusion ...... 585 References ...... 586

CHAPTER 26: FOSTER CARE: HEALTHCARE ISSUES Definition and Description of Foster Care ...... 595 Types of Foster Care ...... 595 Health Issues of Children in Foster Care ...... 596 Physical Health Needs ...... 596 Causes of Illness ...... 596 Physical Health Findings ...... 596 Developmental Needs ...... 598 Developmental Delay in Foster Children...... 598 Causes of Developmental Delay ...... 598

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Mental Health...... 599 Mental Health Status of Children in Foster Care ...... 599 Causes of Mental Illness in Foster Children ...... 600 Healthcare Recommendations ...... 600 Barriers to Care ...... 601 Successful Healthcare Programs ...... 603 Conclusion ...... 604 References ...... 604

CHAPTER 27: FAMILY ABDUCTION Scope and Characteristics of Family Abduction ...... 610 Policy, Legal Response, and Criminalization ...... 611 National Center for Missing & Exploited Children ...... 617 Effect on the Left-Behind Parent ...... 617 Effect on the Abducted Child...... 618 Prevention...... 618 Conclusion ...... 622 References ...... 622

CHAPTER 28: PEDIATRIC SCREENING FOR INTIMATE PARTNER VIOLENCE Definition and Prevalence of Intimate Partner Violence ...... 625 Intimate Partner Violence and Health ...... 625 Recommendations of Professional Organizations ...... 626 Pediatric Studies ...... 626 The Impact of Intimate Partner Violence on Children...... 628 Screening...... 629 Special Considerations ...... 631 International Studies...... 632 References ...... 632 Appendix 28-1: Internet Resources ...... 636 Appendix 28-2: RADAR Card for Screening for Domestic Violence . . . 637

CHAPTER 29: INTERPERSONAL VIOLENCE Intimate Partner Violence ...... 639 Definitions...... 639 Intimate Partner Violence Versus Battering ...... 640 Prevalence and Sequelae ...... 641 Assessment ...... 641 Theories ...... 641 Risk Factors ...... 641 Perpetrator Variables ...... 641 Victim Characteristics ...... 642 Overlap With Parent-Child Violence ...... 644 Child Maltreatment ...... 645 Forms and Definitions ...... 645 Prevalences ...... 646 Cycle of Violence...... 646 Does Child Maltreatment Victimization Lead to Child Maltreatment Perpetration in Adulthood? ...... 647 Does Child Maltreatment Lead to Intimate Partner Violence Perpetration in Adulthood?...... 648 Does Child Maltreatment Lead to Intimate Partner Violence Victimization in Adulthood? ...... 648 Does Child Exposure to Parental Intimate Partner Violence Lead to Child Maltreatment Perpetration in Adulthood? . . 649 xxxiv Contents in Detail

Does Child Exposure to Parental Intimate Partner Violence Lead to Intimate Partner Abuse Perpetration in Adulthood?...... 649 Does Child Exposure to Parental Intimate Partner Violence Lead to Intimate Partner Abuse Victimization in Adulthood? ...... 649 Does Child Victimization and Exposure to Parental Intimate Partner Violence Lead to Child Maltreatment Perpetration in Adulthood? . . 649 Does Child Victimization and Exposure to Parental Intimate Partner Violence Lead to Intimate Partner Abuse Perpetration in Adulthood? . 650 Does Child Victimization and Exposure to Parental Intimate Partner Violence Lead to Intimate Partner Abuse Victimization in Adulthood? ...... 650 Does Child Victimization or Exposure to Parental Intimate Partner Violence Lead to Violent Criminal Behavior? ...... 650 Problems With Cycle of Violence Research ...... 650 Summary ...... 651 How Does the Cycle of Violence Operate? ...... 651 Observational Learning...... 651 Aftermath of Ineffective Parental Discipline ...... 651 Biological and Genetic Factors ...... 652 Conclusion ...... 652 References ...... 652

CHAPTER 30: THE ROLE OF LAW ENFORCEMENT IN THE INVESTIGATION OF CHILD MALTREATMENT Law Enforcement Role: The Officer and the Organization ...... 660 Preliminary Investigative Actions ...... 663 Child Protective Services ...... 663 Collaboration Between Law Enforcement Agencies and Child Protective Services ...... 663 Multidisciplinary Teams...... 664 The Law Enforcement Investigation ...... 667 Interview Guidelines...... 668 General Interview Preparations ...... 668 The Victim Interview ...... 671 The Witness Interview ...... 673 Interrogating the Suspected Perpetrator ...... 674 Special Investigative Techniques ...... 675 Crime Scene Search ...... 676 When a Child Dies: Investigating Child Fatalities ...... 680 Preparing a Report ...... 681 Conclusion ...... 681 References ...... 682 Appendix 30-1: Sample Affidavits and Search Warrant Applications From the State of Missouri...... 685 Appendix 30-2: Multidisciplinary Preliminary Investigative Checklist for Serious Children’s Events ...... 698 Preliminary Investigative Checklist ...... 698 Appendix 30-3: Child Fatality Review Programs ...... 702 Appendix 30-4: Determining Cause and Manner of Death ...... 704

CHAPTER 31: LEGAL ISSUES Reporting Suspected Abuse and Neglect ...... 707 Child’s Description of Maltreatment During Physical Examination or Questioning: Hearsay and Its Exceptions...... 707 The Excited Utterance Exception ...... 708

xxxv Contents in Detail

The Medical Diagnosis or Treatment Exception ...... 708 The Residual and Child Hearsay Exceptions ...... 709 Importance of Documentation ...... 710 Forensically Defensible Questioning ...... 710 Confidential Records and Privileged Communications ...... 713 Ethical Duty to Safeguard Confidential Information ...... 713 Laws that Make Patient Records Confidential ...... 713 Privileged Communications...... 713 Disclosure of Confidential and Privileged Information ...... 714 Patient Consent to Release of Information ...... 714 Limitations on Privileges ...... 714 Reviewing Client Records Before or During Testimony . . . . . 714 Child Abuse Reporting Laws Override Confidentiality and Privilege . 715 Psychotherapist’s Duty to Warn Potential Victims About Dangerous Clients ...... 715 Emergencies ...... 715 Court-Ordered Examinations...... 715 Expert Testimony in Child Abuse Litigation...... 715 Who Qualifies as an Expert Witness? ...... 715 Preparation for Expert Testimony ...... 715 Form of Expert Testimony ...... 716 Opinion Testimony ...... 716 The Hypothetical Question...... 716 A Background Lecture to Educate the Jury ...... 716 Cross-examination and Impeachment of the Expert Witness . . . . . 717 Raise Doubts About the Expert’s Testimony ...... 717 Leading Questions ...... 717 Limit the Expert’s Ability to Explain ...... 717 Undermine the Expert’s Assumptions ...... 717 Impeach with a “Learned Treatise”...... 718 Raise the Possibility of Bias ...... 718 Responding to Subpoenas ...... 719 What Is a Subpoena? ...... 719 Should I Contact the Patient Before I Respond to a Subpoena? . . . . 719 Should I Seek Legal Advice?...... 720 Should I Talk to the Attorney Who Issued the Subpoena? ...... 720 What if the Patient Does Not Want Me to Respond to the Subpoena? . . 720 Conclusion ...... 720 References ...... 721

CHAPTER 32: PREPARING A CASE FOR COURT Unique Challenges of Criminal Prosecution ...... 723 Public and Jury Attitudes Toward Abuse ...... 723 Interface of Medical Science and Criminal Justice ...... 724 Proof Beyond a Reasonable Doubt: Circumstantial Evidence . . . . . 724 Proving the Child Sexual Abuse Case...... 725 Process of Disclosure by Child Victims ...... 725 Medical Evidence ...... 726 Interviews by Medical Personnel ...... 727 Expert Testimony in Sexual Abuse Cases...... 728 Child Victim as a Witness ...... 728 Multidisciplinary Team ...... 728 Interview Protocols ...... 730 Corroborating the Child’s Disclosure ...... 731 Other Acts of Abuse to Corroborate Sexual Abuse ...... 731 xxxvi Contents in Detail

Preparing the Child for Court and the Court for the Child Witness . . . 732 Interviewing the Suspect...... 734 Common Defenses ...... 735 Proving Child Physical Abuse and Homicide by Abuse ...... 736 Expert Witness Testimony to Prove Injuries ...... 736 Choosing the Right Experts...... 736 Educating the Judge and Jury ...... 737 View From the Expert Witness Chair ...... 738 The Expert as Consultant to the Prosecutor ...... 740 Nature, Location, Timing, and Mechanism of Injuries ...... 740 Mechanism ...... 741 Timing...... 742 Alternative Theories of Causation...... 743 Proving the Perpetrators of Abuse and Their Mental State . . . . . 744 Synthesis of Expert Opinion and Investigative Fact ...... 744 Establishing a Timeline ...... 744 Factors Differentiating Among Possible Perpetrators ...... 745 Establishing the Mental State of the Perpetrator of the Crime . . . 745 Charging the Nonabusive Partner...... 746 Confronting the Defendant’s Case ...... 746 Alibi, Character, and Other Defense Witnesses ...... 746 Cross-examination of the Defendant ...... 747 Defense Medical Witnesses ...... 748 Vital Aspects of Persuasion in the Courtroom ...... 751 Opening Statement: What the Trier of Fact Needs to Know . . . . 751 Use of Visual and Demonstrative Evidence ...... 751 Personalizing the Victim ...... 752 Closing Argument ...... 753 Conclusion ...... 754 References ...... 754 Appendix 32-1: List of Factors to Consider in Determining Who Likely Committed the Crime ...... 757

CHAPTER 33: PREPARING TO GIVE EXPERT TESTIMONY Pretrial ...... 761 The Clinical Evaluation...... 761 The Special Circumstance of Hearsay ...... 762 Preparing for Court ...... 763 Trial ...... 764 Civil Child Protective Versus Criminal Court ...... 764 Legal Proof Versus Medical Proof ...... 765 Experts and Expert Testimony ...... 765 Successful Testimony ...... 767 Opposing Counsel Tactics ...... 768 Irresponsible Expert Testimony ...... 768 Conclusion ...... 771 References ...... 771

CHAPTER 34: ROLE OF THE MEDICAL EXAMINER IN FATAL CASES Mortality Attributed to Physical Abuse ...... 773 Factors Affecting Investigation ...... 774 Determining Cause of Death ...... 774 Determining Mechanism of Death ...... 775 Determining Manner of Death ...... 776 Medicolegal Evaluation of Death ...... 776

xxxvii Contents in Detail

Investigation Process ...... 777 Investigation Components...... 777 History ...... 777 Chief Complaint With History of Injury or Death ...... 777 Case History Review ...... 777 Physical Examination ...... 778 Scene Investigation ...... 778 Postmortem Examination ...... 778 Gross External Observation ...... 779 Examination of Soft Tissues and Visceral Organs ...... 779 Ancillary Studies ...... 780 Radiological Data ...... 780 Laboratory Data ...... 780 Data Interpretation ...... 781 Interpretation of Injuries ...... 781 Aging of Injuries...... 782 Patterned Injuries and Injury Patterns ...... 783 Patterned Injuries ...... 783 Blunt Injury Patterns ...... 783 Lethal Injuries ...... 785 Blunt Head Trauma ...... 785 Skull Fracture ...... 786 Intracranial Hemorrhage ...... 787 Shaking...... 787 Intrathoracic Injuries ...... 790 Intra-abdominal Injuries...... 790 Other Blunt Force Injuries...... 790 Mechanical Asphyxia ...... 792 Strangulation ...... 792 Smothering ...... 792 Overlying...... 792 Choking ...... 793 Other Causes of Death ...... 793 Poisoning ...... 793 Burns ...... 793 Scalding ...... 794 Neglect ...... 794 Physical Findings...... 795 Alternative Care ...... 795 Munchausen Syndrome by Proxy ...... 796 Sexual Abuse ...... 796 Conditions That Are Not Abuse ...... 796 Sudden Infant Death Syndrome ...... 796 Mongolian Spot ...... 796 Metabolic and Other Disorders ...... 796 Injuries Related to Therapeutic Intervention ...... 797 Iatrogenic Injuries ...... 797 Folk Medicine ...... 797 Postmortem Changes ...... 797 Organ and Tissue Transplantation Issues ...... 798 References ...... 799

CHAPTER 35: CHILD FATALITY REVIEW TEAM Historical Development ...... 806 Child Fatality Review: A National Perspective ...... 809 xxxviii Contents in Detail

Child Fatality Review: State Experiences ...... 816 The Autopsy...... 824 Prevention: The Ultimate Goal ...... 826 Conclusion ...... 831 References ...... 831 Appendix 35-1: Child Fatality Review Examples from Missouri . . . . . 837 Appendix 35-2: Examples From CDC ...... 847

CHAPTER 36: FORENSIC EVIDENCE COLLECTION Indications ...... 856 The Procedure ...... 856 Clothing ...... 857 Specimens for Seminal Products ...... 857 Hair Specimens ...... 857 Foreign Debris ...... 857 Blood Specimens ...... 858 The Chain of Evidence ...... 858 References ...... 858

CHAPTER 37: DNA EVIDENCE Understanding the Serological Past ...... 861 The Forensic DNA Revolution ...... 862 Restriction Fragment Length Polymorphism Analysis...... 863 Polymerase Chain Reaction Analysis...... 864 Diversity of Polymerase Chain Reaction Forensic Tests ...... 864 Convicted Offender Databases...... 865 Combined DNA Index System...... 865 Success Stories ...... 866 The DNA Testing Resource Crisis...... 867 Message to Law Enforcement and the Judicial System ...... 868 Handling Biological Evidence in Sexual Assault Cases...... 869 DNA Case Histories...... 869 DNA Collection...... 871 Gaining Cooperation of the Child ...... 871 Acute Examinations...... 873 Law Enforcement Investigation ...... 875 DNA Evidence as a Prosecutorial Weapon ...... 875 Lack of DNA Training for Law Enforcement and Forensic Examiners . . 876 Suspect Examinations ...... 877 Reexamining Unsolved Sexual Assault Cases ...... 877 Evaluation of the Critical Shortage of Crime Laboratory Resources . . . 878 Case-to-Case Cold Hits...... 879 Resource Management ...... 880 Communication Needed Between Investigators and Criminalists . . . 880 Appendix 37-1: Case Studies ...... 882 Appendix 37-2: Documentation and Warrants ...... 898 Prepubescent Sexual Assault Information ...... 898 SART Cloting Documentation...... 901 Search Warrant for the Unconscious Victim ...... 903 Sexual Assault Suspect Examination ...... 905 Search Warrant ...... 910 Forensic Sciences–Preliminary Rape Case Information ...... 912 Forensic Sciences–Lab Services Request ...... 913 References ...... 914

xxxix Contents in Detail

CHAPTER 38: MULTIDISCIPLINARY TEAMS The Need for a Collaborative Approach ...... 917 Perceived Barriers to Interagency Collaboration ...... 918 Conflicting Mandates and Goals...... 918 Varied Approaches to Decision Making ...... 920 Limitation of Resources and Administrative-Level Support . . . . . 920 Lack of Familiarity With Other Disciplines ...... 921 Fear of Loss of Control ...... 924 Physical Distance ...... 924 Attitudes ...... 925 Interagency Relationships: Overcoming Barriers in a Stepwise Fashion . . 925 Interagency Cooperation ...... 926 Interagency Coordination ...... 927 Interagency Collaboration...... 928 Utilization of Technology to Advance Collaborative Efforts ...... 931 Conclusion ...... 932 References...... 933

CHAPTER 39: ROLE OF PHYSICIAN AND NURSE EDUCATION The Child Maltreatment Healthcare Evaluation: Roles for Physicians and Nurses ...... 936 Physician Training ...... 937 Pediatric Residency Training About Child Maltreatment: An Evolving Literature ...... 937 Related Training Issues: Prepubertal Genital Examination and Recognition of Genital Anatomy ...... 944 The Frequency of Including the Prepubertal Genital Examination . . 944 Recognition of Prepubertal Genital Anatomy ...... 944 Practicing Physician Issues Regarding Child Sexual Abuse ...... 945 Training Issues for Nonpediatric Residents and Fellows ...... 946 Pediatric Emergency Medicine Fellows ...... 946 Emergency Medicine Residents ...... 947 Family Medicine Residents ...... 948 Psychiatric Residents ...... 948 Nurse Training ...... 949 Emergency Department Nurses ...... 949 The National Association of Pediatric Nurse Practitioners ...... 949 International Nursing Perspective ...... 950 Sexual Assault Nurse Examiner ...... 950 Calls for National Curricula Related to Child Maltreatment in Pediatric Residency and Beyond ...... 952 Approaches in Child Maltreatment Education ...... 960 Example I: A Non–Rotation-Based Longitudinal Approach . . . . . 963 Assessment ...... 966 Example II: A Day-Long Training Approach ...... 968 Assessment ...... 969 Example III: A Training Program for Practicing Physicians . . . . . 972 Conclusion ...... 972 References ...... 973

CHAPTER 40: OPPORTUNITIES FOR FEDERAL FUNDING AND COLLABORATION: THE NATIONAL INSTITUTES OF HEALTH CHILD ABUSE AND NEGLECT WORKING GROUP Research Criticism and Medical Research Agenda ...... 981 Establishment of the National Institutes of Health Child Abuse and Neglect Working Group...... 989 xl Contents in Detail

Objectives of the Child Abuse and Neglect Working Group . . . . . 989 Major Focus Areas of the Child Abuse and Neglect Working Group . 990 Research on Child Neglect...... 993 Career Development...... 993 Definitions ...... 995 Current Goals and Activities ...... 999 Directions for the Future ...... 1000 References ...... 1000

CHAPTER 41: PUBLIC CHILD WELFARE: A HISTORY OF CHALLENGE AND OPPORTUNITY Evolution of the Child Welfare System ...... 1003 Early History ...... 1003 Child Protection Laws...... 1004 Development of Orphanages ...... 1004 The Beginnings of a National Awareness of Child Maltreatment . . . 1005 Development of Medical Awareness and the Battered Child Syndrome . 1006 Legislative Mandates ...... 1007 Child Abuse Prevention and Treatment Act ...... 1007 Adoption Assistance and Child Welfare Act ...... 1007 Indian Child Welfare Act ...... 1007 Family Preservation and Family Support Program and the Multiethnic Placement Act ...... 1008 Adoption and Safe Families Act ...... 1008 How the Current System Works ...... 1008 Outcomes In Child Welfare ...... 1009 Outcomes and Managed Care ...... 1009 Outcomes Model Development ...... 1010 Philadelphia Outcome Measures Project ...... 1010 Child and Family Service Review ...... 1012 Interagency Partnerships ...... 1013 Child Maltreatment ...... 1013 Children in Foster Care ...... 1013 Multiple-Problem Families ...... 1016 Service Delivery System ...... 1016 Obstacles to Partnerships ...... 1017 Professional Preparation and Training ...... 1017 Client Focus ...... 1017 Timetables ...... 1017 Legal Issues ...... 1018 Workloads ...... 1018 Partnerships ...... 1019 Community ...... 1019 Social Service System ...... 1019 School ...... 1020 Higher Education ...... 1021 Law Enforcement ...... 1021 Courts ...... 1021 Healthcare ...... 1022 Child Welfare Workforce Issues ...... 1022 Workforce Shortage...... 1022 Turnover Rates ...... 1023 Salaries ...... 1023 Attracting and Retaining Staff ...... 1023 Policy Implications ...... 1024

xli Contents in Detail

Looking to the Future ...... 1024 Current Climate and the Future of Child Welfare ...... 1024 References ...... 1026 Appendix 41-1: Family Resource Scale...... 1029

CHAPTER 42: ROLE OF THE SOCIAL WORKER Child Maltreatment: “Private Trouble” and “Public Issue” ...... 1031 Defining Child Abuse and Neglect ...... 1032 Defining Social Work ...... 1033 What is a Social Worker? ...... 1034 Decision Making ...... 1034 Critical Thinking ...... 1038 Evidence-Based Practice ...... 1039 Assessment ...... 1041 Empirically Supported Interventions...... 1042 Child-Focused Interventions ...... 1043 Parent-Focused Interventions ...... 1045 Multicomponent Interventions ...... 1046 Behavioral and Cognitive Behavioral Interventions ...... 1046 Parent Education ...... 1047 Social Network Interventions ...... 1048 Ecobehavioral Interventions (Project 12 Ways)...... 1048 Conclusion ...... 1049 Resources on the Internet ...... 1050 References ...... 1050

CHAPTER 43: PREVENTION The Importance of Prevention ...... 1063 Roles of Pediatricians ...... 1064 Defining Physical Child Abuse and Neglect ...... 1065 Types of Prevention ...... 1065 The Etiology of Child Abuse and Neglect: Risk and Protective Factors . . 1066 Parent-Child Dyad...... 1066 Family and Community Context ...... 1067 Societal Contexts ...... 1068 Screening ...... 1069 Building on Prior Research ...... 1069 Building on Clinical Experience ...... 1069 Introducing Sensitive Questions ...... 1069 Gathering the Information ...... 1070 Confidentiality ...... 1070 Assessment ...... 1070 Management ...... 1071 Community Resources ...... 1072 Advocacy...... 1073 Challenges ...... 1074 References ...... 1075 Appendix 43-1: Seeking: A Safe Environment for Every Child . . . . 1083 Appendix 43-2: Screening Questions for Assessment ...... 1084 Depression ...... 1084 Substance Abuse ...... 1085 Domestic Violence ...... 1086 Discipline ...... 1089

xlii THIRD EDITION

G.W. Medical Publishing, Inc. St. Louis 1 Chapter

OVERVIEW OF CHILD MALTREATMENT John M. Leventhal, MD

Since 1962, when Kempe and colleagues first described the “battered child syn- drome,”1 it has become increasingly clear that child maltreatment, including physical abuse, neglect, sexual abuse, and emotional abuse, is far too common, has profound short- and long-term effects on children and families, and is extremely costly to society. It also has become clear that much greater attention and financial support will be necessary to increase dramatically the efforts aimed at preventing child mal- treatment and supporting families. Before the article by Kempe and colleagues, observant radiologists raised important questions about how major injuries, such as fractures, occurred in young children and hesitantly proposed that these injuries were the result of actions by the caregivers.2,3 Others, such as Adelson,4 wrote about the killing of children. Kempe’s article, however, provided a major shift in the understanding of certain poorly explained childhood injuries that were seen by countless clinicians around the country. Whereas some clinicians had not recognized that parents and other caregivers were hurting their children, others likely had recognized the problem but had kept quiet about it because it was too painful and difficult to believe. Kempe and his coauthors provided information about both the clinical spectrum of the battered child syndrome and the first epidemiological study, in which 749 abused children were identified around the country. It seems very unlikely that anyone at that time could have envi- sioned what has been learned about the problem’s extent over the last 4 decades. The recognition of abused children created new problems and questions for hospitals and clinicians. What is the home like where the child was abused? Is it safe to send the child home, and, if not, where should the child go? In response to these types of ques- tions and others and the need to protect children, state and federal legislation in the 1960s and 1970s established child protective services (CPS) agencies in each state, and laws were passed mandating that physicians and other professionals report suspected abuse to CPS. DEFINITIONS AND EPIDEMIOLOGY Maltreatment of children includes neglect, physical abuse, sexual abuse, and emo- tional maltreatment. Neglect is defined as acts of omission and includes the failure to provide adequate nutrition, clothing, shelter, or supervision; abandonment; and failure to ensure that the child receives adequate healthcare, dental care, or education. Although neglect can be a single event, such as leaving a young child unsupervised in an unsafe setting, it often is a pattern of unsafe or inadequate care, such as a pattern of inadequate supervision or inadequate nutrition because of a serious mental health problem or substance abuse on the part of the caregiver. Physical abuse is defined as acts of commission toward the child by a parent or caregiver. Such acts can result in harm to the child or they might intend to harm, although there may be no harm or only a minor injury. It can include injuries that occur when a child is punished severely or when a parent loses control and shakes a crying infant. Injuries that are

1 Child Maltreatment—A Clinical Guide and Reference

suspicious for abuse or neglect must be distinguished from unintentional (or acci- dental) injuries. Also, clinicians must take care to distinguish neglect from episodes of less serious failures to provide adequate care to a child, such as when a 10-month-old rolls off of a bed or a child has missed a few appointments for well-child care and has not received all of the appropriate immunizations. Sexual abuse is the involvement of adults, older children, or adolescents in sexual activities with children who cannot give appropriate consent and who do not un- derstand the significance of what is happening to them.5 Such activities violate family and societal taboos. Sexual abuse includes, for example, sexual touching of the genitalia, oral sex, attempted or actual sexual intercourse, or including children in child pornography. Although a 5-year age difference between “victim” and “per- petrator” is often used to decide whether sexual behaviors between two children should be considered sexual abuse, as opposed to “sexualized play,” it is often more helpful to examine how invasive and persistent the behaviors are by the older child and whether the younger child wanted the behaviors to stop and felt threatened. Emotional (or psychological) maltreatment is “a repeated pattern of damaging inter- actions between parent(s) and child that become typical of the relationship.”6 This form of maltreatment occurs when a child repeatedly feels that he or she is unwanted, unloved, or worthless. It includes denigration, belittling, and ridiculing; it also can include actively rejecting the child or ignoring the child’s emotional needs. Although emotional maltreatment is likely the most common form of maltreatment, children are infrequently reported to CPS agencies for emotional maltreatment. Emotional maltreatment, however, often accompanies other types of abuse or neglect and plays a major role in the consequences of these types of maltreatment. Much has been learned about the epidemiology of child maltreatment. Since 1976, each year in the United States, data are collected from each state’s CPS agency to track the number of reports and substantiated cases. By the early 1990s, there were over 3 million reports nationwide, and approximately one third of these reports were substantiated, meaning that the local CPS agency had enough evidence to believe that child maltreatment had occurred. From 1992 to 1999, there was a 14% decline in the yearly tally of substantiated reports of maltreatment. Although substantiated cases of abuse and neglect each declined, the largest decline (39%) occurred nationwide in substantiated reports of sexual abuse.7 It is difficult to know how much of this decrease was the result of a true change in the occurrence of the phenomenon and how much was the result of other changes, such as the criteria used by CPS to substantiate reports of sexual abuse or how specific reports are categorized as abuse, neglect, or sexual abuse.8 In 2001 there were 2.7 million reports to CPS agencies nationwide, and 903 000 cases were substantiated as being victims of maltreatment.9 Thus 12.4 per 1000 children were subjects of a substantiated report of maltreatment. Of these, 59% were caused by neglect, 19% by physical abuse, 10% by sexual abuse, 7% by emotional maltreatment, and 5% by other high-risk situations. In addition, approximately 1300 children died because of abuse or neglect. The majority of these children were youn- ger than 6 years, and over 40% were younger than 1 year old. Experts believe that deaths caused by abuse or neglect may be significantly undercounted,10 and as many as 2000 children may die each year because of maltreatment.11 The data from CPS agencies are based only on cases of child maltreatment that are actually recognized in the community and reported to and substantiated by CPS; therefore at least 4 other approaches have been used to examine the occurrences of child maltreatment, as follows: 1. Prospective data collection in selected communities to identify cases of mal- treatment, even if not reported to CPS. This approach has been used in 3

2 2 Chapter

SKELETAL AND VISCERAL RADIOLOGICAL IMAGING E. Isin Akduman, MD Gregory D. Launis, MD Atchawee Luisiri, MD Michael J. Silberstein, MD E. Richard Graviss, MD

The role of radiology in child abuse is threefold: (1) identifying traumatic injury; (2) recognizing abusive origin; and (3) employing the optimal imaging modality to document findings. The radiologist’s strength lies in identifying the type, extent, and age of the child’s injury, as well as in distinguishing between accidental and non- accidental injury because the recognition of nonaccidental injury opens the door to intervention, thereby breaking the cycle of abuse. The pediatric radiologist encounters a wide range of injuries resulting from child abuse. The most obvious are the physical injuries from intentionally inflicted trauma. Injuries related to child neglect, although equally important, are more common but harder to detect. Awareness of abuse and its indicators allows the radiologist to characterize the in- juries. Radiographs are most effective in evaluating physical changes to bony structures. With the utilization of additional diagnostic modalities, less obvious but significant internal injuries now can be detected. The radiologist plays a key role on the management team for identification, docu- mentation, reporting, and testimony in cases of child abuse. In recognizing physical abuse, the radiologist must possess an awareness of the likely mechanism of injury and add knowledge of the specificity of radiological findings and the demographics of child abuse.1,2 Often the lack of correlation between injury and the known mechanism required to produce the injury allows for the diagnosis of abuse.3 Maintaining a high index of suspicion for abuse in differential diagnosis allows the radiologist to be among the first to recognize discrepancies between the history and radiographical findings. Then the appropriate imaging studies to provide the optimal information to confirm or deny the possibility of nonaccidental injury are selected. The radiologist’s role includes the responsibility to report suspected child abuse to the proper authorities and to work with them to prevent further injury.4 Usually, radi- ologists act as consultants in those cases, so they must also be cognizant of the laws involved in child abuse. They may be critical in determining if an injury is the result of nonaccidental trauma. The radiologist’s reports have both clinical and legal significance. Therefore, documentation must be complete and accurate. For more detailed reading regarding this topic and responsibilities in court cases and recom- mendations for radiologists, see Diagnostic Imaging in Child Abuse.5 One of the greatest rewards in diagnosing child abuse is the prevention of recurrence. Meticulous attention to technique and interpretation is essential, so confident diagnoses might be validated during future testimony, when necessary.6

13 Child Maltreatment—A Clinical Guide and Reference

It falls within the radiologist’s realm to consider the risk-to-benefit ratio for all examinations. The issue of cost versus diagnostic benefit is subjective and difficult to evaluate, given the implicit ethical considerations. Potential risks from ionizing radiation and complications of contrast or sedation must be weighed against the benefit of preventing further abuse. In summary, the pediatric radiologist plays a strategic role in the diagnosis of abuse. Awareness of the mechanisms of injury and selecting the optimal imaging modality for the specificity of findings, make the pediatric radiologist a key member in the team of caregivers for the abused or neglected child (Table 2-1). ODALITIES Table 2-1. Key Plain Film Findings Suspicious of Abuse M The radiologist has multiple methods available for evaluating bony and soft — The metaphyseal-epiphyseal fracture, occurring at the ends of long bones, tissue structures, including X-ray films, the acromial process of the scapula, and the clavicular ends nuclear medicine, computed tomogra- — Rib fractures in infants, multiple rib fractures, or posterior location (Rib phy, magnetic resonance imaging, and fractures are uncommon sequelae of delivery or CPR.) ultrasound. — Fractures in multiple stages of healing DIAGNOSTIC RADIOGRAPHS Radiographs provide the foundation for — Long-bone fractures in children who are not ambulatory (under 12 months) imaging nonaccidental injury in child- — Vertebral fractures in infants (requires neurological and skeletal follow-up) ren. The radiographic skeletal survey has its highest yield in children under the — Infantile subdural hematomas (in the absence of appropriate history and age of 2 years. After this, a more directed external signs) approach can be used; after the age of 5 — Skull fractures that are depressed, cross the midline, or occipital years, complete screening is usually un- necessary. Bone injuries by themselves rarely result in long-term handicapping conditions. When performing radiolog- ical studies for bone injuries, the greatest benefit derived from documenting and dating abuse is prevention of recurrence. The skeletal survey should include: a two-view chest with bone technique, right and left oblique views of the ribs, two skull views, lateral thoracolumbar spine, anteroposterior (AP) pelvis, and AP views of the upper and lower extremities, posteroanterior (PA) hands and feet7 and a lateral C-spine,8 the result of reported cases of cervical fractures9 and a case of hangman’s fracture.10 Although the number of radiographs will vary with the size of the patient, the use of a single image, formerly called a “babygram”, is no longer acceptable.11 Further examinations may be added when abnormalities are detected on the critical series. Maintenance of high technical standards is important in obtaining radiographs in child abuse. One of the most frequent causes of missed or overdiagnosed cases of child abuse relates to poor-quality radiographs. According to the American College of Radiologists (ACR), an imaging system used for suspected abuse should have a spatial resolution of 10 line pairs (lp) per mm and a speed of no more than 200. Although digital or filmless radiology is replacing film screen radiography in many areas, the detail should be comparable to high-detail screen radiography before it can be used routinely for child abuse.12

NUCLEAR MEDICINE Radiopharmaceuticals can be tagged and delivered to specific organs. Long scan times are required during imaging by the gamma camera. In young children, sedation is frequently required. Radioisotope doses must be calculated specific to each child’s weight to minimize exposure.13 In addition, potassium perchlorate administration is useful to decrease the thyroid dose in technetium studies.13 In child abuse, bone imaging can reveal osseous injuries not identified on standard radiographs11 or clarify equivocal radiographical skeletal survey findings having a high

14 3 Chapter

HEAD INJURY Suzanne P. Starling, MD

Head injury in children has become a well-recognized manifestation of child abuse within the past few decades, but as recently as 30 years ago the diagnosis was unknown. In 1946, pediatric radiologist John Caffey1 described 6 children with chronic subdural hematomas and multiple long-bone fractures unexplained by his- tory of injury or illness. At the time the connection between inflicted trauma to the skeleton and head injury was unrecognized, and Caffey merely concluded that “fractures of the long bones were common complications of infantile subdural hematoma.” In the early 1970s, however, both Caffey2 and Guthkelch3 came to in- dependent conclusions regarding the whiplash mechanism of injury as a cause of subdural hematomas in children. Caffey4 outlined a case of a nanny who had shaken and killed several infants in her care, thus naming the syndrome the whiplash shaken infant syndrome. Since the publication of these landmark papers, numerous pub- lished studies have increased our understanding of the manifestations and mechan- isms of injury in abusive head trauma (AHT). Serious head injury is uncommon in infancy, and the absence of documented severe accidental trauma should raise the suspicion of inflicted injury. Bruce and Zimmerman,5 in their review of head injury data, found that 80% of childhood deaths from head injury were the result of nonaccidental trauma. Billmire and Myers6 found that 95% of serious intracranial injury and 64% of all head injury in infants were the result of child abuse and concluded that child abuse was the leading cause of serious head injury in infants younger than 1 year of age. Children with AHT suffer more severe injuries and have a higher mortality than accidentally injured children.7 As a result, head injury is the leading cause of mortality in abused children.8,9 Infants and young children may be injured by the application of contact or rotational force to the head (Table 3-1). Contact force occurs during falls or other blunt trauma and can cause bruising, fracture, or certain intracranial injuries. Repetitive rotational forces, such as those that occur during shaking, can cause serious intracranial injury with no external evidence of injury.

Table 3-1. Spectrum of Head Injuries in Abusive Head Trauma

PRIMARY CONTACT INJURIES

Example: Impact blow to head — Soft tissue injury — Subgaleal hemorrhage — Subperiosteal hemorrhage — Skull fracture

(continued)

37 Child Maltreatment—A Clinical Guide and Reference

Table 3-1. (continued)

— Focal intracranial hemorrhage underlying skull fracture or impact site — Focal parenchymal injury underlying skull fracture or impact site — Focal parenchymal injury distant from contact site PRIMARY ROTATIONAL INJURIES

Example: Shaking — Subdural hemorrhage not associated with skull fracture — Concussion without prolonged traumatic coma — Immediate loss of consciousness with prolonged traumatic coma PRIMARY HYPOXIA/ISCHEMIA

Example: Strangulation, suffocation — Focal cerebral edema — Diffuse cerebral edema SECONDARY HYPOXIA/ISCHEMIA

Example: Occurs as a result of a primary injury above — Focal cerebral edema — Diffuse cerebral edema — Skull fracture

BLUNT IMPACT HEAD INJURY EXTERNAL CRANIOFACIAL INJURY Minor blunt head trauma in children is common and is caused by both accidental and inflicted mechanisms. Inflicted impact injuries can result from many different scenarios, such as a blow to the head with a fist or other object or by throwing or swinging a child so that the head strikes a surface. Head impact can be single or multiple and produce many different types of injuries. External injuries that should be screened for in suspected abusive trauma include lacerations, abrasions, or con- tusions of the face, ears,10,11 or scalp. Facial bruising below the forehead in infants is uncommon and should raise the suspicion of inflicted injury.12 In a child who is cruising or walking, however, bruising injuries of the forehead and other bony prominences are common accidental injuries, and bilateral black eyes can result from a single blow to the forehead or anterior scalp with subsequent migration of blood under the skin. The absence of visible injury to the scalp does not preclude impact head trauma.13 If the head strikes a broad surface, the underlying scalp injury may be more diffuse and not visible externally. Often a scalp hemorrhage that may not be appreciable externally is found on computed tomography (CT) scans or at autopsy (Figure 3-1). Scalp impact may present as a soft fluctuant mass with or without overlying bruising. Simple subcutaneous scalp bleeding can be seen with minor impact trauma to the head and consists of hematoma or a “goose egg” limited to the subcutaneous tissue. One well-known manifestation is the caput succedaneum, or occipital subcutaneous Figure 3-1. CT showing significant subgaleal bleeding occurring during childbirth. A cephalhematoma, also seen in childbirth, hemorrhage overlying a skull fracture. is a deeper hemorrhage under the fibrous periosteum covering the skull. The

38 INDEX in seminal fluid, 855t A Acidosis Abandonment, 174-176 in drug ingestion, 142-144 of disabled child, 170, 578 in failure to thrive, 200 of infant, 170t Acquaintance as perpetrator, 210 as response to abduction, 619 Acquired immunodeficiency syndrome, 299-303. See also Abdomen, bruise on, 70 Human immunodeficiency virus infection Abdominal injury, 105-106 Activist therapist, 420 evaluation of, 109-110 Acute examination, 873-875 imaging of, 27-30 Acute injury, 272, 742 postmortem examination of, 790, 791f Acyclovir, 304-305, 310t Abdominal pain, 139t Adaptive behavior of disabled child, 575 Abduction, family, 609-622 Admissible evidence, drawing as, 462 AMBER alert plan for, 610 Admissible statement, 727 characteristics of, 610-611 Admission of guilt by parent, 423 effects of, 617-618 Adolescent legal response to, 611-616 access to Internet by, 510, 512 National Center for Missing & Exploited Children development in, 348-349 and, 617 evidence collection from, 872 overview of, 609 in foster care, 596 prevention of, 618-619 indicators of sexual abuse of, 483 reunion of child with parent, 620t prophylaxis for sexually transmitted disease in, 290-291, scope of, 610-611 294t ABO blood type, 861 psychological maltreatment of, 330-331 Abuse. See Maltreatment psychopathology in, 367-385. See also Psychopathology Academic skills, 490-491 as sex offender, 211 Access suicide related to abuse and, 373-374, 377-379 to child, in religious institution, 543, 548 trust by, 484 to electronic media, 505-510 Adoption and Safe Families Act, 1008 to Internet, 505-510, 512, 516 Adoption Assistance and Child Welfare Act, 1007 Accident Adult vs. child in diagnosis of sexually transmitted disease, abusive head injury vs., 49-50 290t choking as, 793 Adversarial process, 767 neglect-related, 583 Advisory Board on Child Abuse and Neglect, 928 Accidental burn Advocacy contact, 74 as law enforcement role, 661 pattern of, 794 prevention and, 1073-1074 Accidental disclosure of abuse, 726 roles and responsibilities in, 923t Accidental injury, 274-275 Affidavit in support of search warrant, 678, 685-697 defense claim of, 749-750 Affect regulation, 358 in differential diagnosis of abuse, 31 African American, health status of, 565 Accommodation syndrome, 211-212 Age Accountability of religious personnel, 546t, 547-548 artistic development and, 451-454 Accumulation of risk model, 327 of injury, 782-783 Acetaminophen poisoning, 127t memory and, 346t, 347-348 Acetone poisoning, 128t psychological maltreatment and, 321-322, 330-331 Acid phosphatase, 270, 679, 853-855, 883 Agglutination, labial, 274, 275f as evidence, 854 Aggravation of condition in Munchausen syndrome by

1091 Child Maltreatment—A Clinical Guide

proxy, 401 Anesthesia, 215, 307t, 960t, 963t Aggression Anger, 322-323, 329 maltreatment related to, 375t, 383 Animal bite, 96 physical maltreatment related to, 368-369 Anion gap, 142-143 psychological maltreatment and, 329-330 Annenberg Public Policy Center, 511, 524, 525 Agitation, drug ingestion causing, 138t Anterior chamber, 84 Aid to Families With Dependent Children, foster care and, 599 Anthropological study, 565-568 Air freshener, poisoning with, 129t Antibiotic prophylaxis, 290-291, 294t Alcohol Antibody, hepatitis B virus, 308t to facilitate sexual abuse, 121-122 Anticipatory guidance, 1072 fetal exposure to, 581 Antidepressant, poisoning with, 126t-127t unintentional ingestion of, 135 Antigen, hepatitis B virus, 308t Alcohol abuse Antiretroviral prophylaxis, postexposure, 302-303 confrontation skills in, 488-489 Antisocial behavior, 373 neglect and, 168 Anus as risk factor, 1066 anatomy of, 268-271 Aldolase, 141 healed injury of, 276, 277f Alibi, 746-747 Anxiety disorder, 372t Allegation of abuse Apnea false, 216-217, 425-428 drug ingestion causing, 138t religious institution’s response to, 547-548 in Munchausen syndrome by proxy, 395, 402 Alternative care in death of child, 795 Apple juice concentrate, poisoning with, 129t, 139t Alternative medicine, 567 Application for search warrant, 685-697 Alternative theory of causation, 743-744 APSAC Handbook on Child Maltreatment, 925 AMBER alert, 610t Arrest, cardiac, 104 Ambulatory Pediatric Association, 952-957 Arsenic poisoning, 120t, 130t, 139t American Academy of Family Practice, 626 Art. See Drawing American Academy of Family Physicians, 627t Art therapy, 422 American Academy of Pediatric Dentistry, 98 Arterial blood gases, 142 American Academy of Pediatrics, 932 Artistic development, 451-454 anal contact and, 270 Asher, Richard, 396 criteria for reporting maltreatment, 64t Asphyxiation, 580 on domestic violence screening, 626, 627t, 630 postmortem examination of, 792 on foster care, 598-599, 601 Assault. See Intimate partner violence; Physical abuse; on legal issues affecting child, 350 Sexual abuse on sexual abuse, 214 Assessment American Art Therapy Association, 460-461 by child protective services, 664t American Board of Forensic Odontology, 96 drawing in, 449-465. See also Drawing American College of Physicians, 626, 627t of foster child, 603 American College of Radiologists, 14 of intimate partner violence, 641 American Dental Association, 99-101 prevention and, 1070-1071 American Dental Hygienists’ Association, 100 psychological, 409-418, 428-432 American Journal of Emergency Medicine, 115 general measures for, 428-429 American Medical Association overview of, 409 on domestic violence screening, 626, 627, 631 psychophysiological, 430-431 on expert testimony, 770 specialized tools for, 429-430 American Professional Society on the Abuse of Children, 430 questions for, 1083-1090 American Public Welfare Association, 663 by social worker, 1041 Americans with Disabilities Act, 584 Asymmetric growth restriction, 198 Amnesia, dissociative, 429-430 Ataxia, 128, 134, 138t Amusement as motive for chemical ingestion, 118, 124 Atrophy Anatomy after intracranial injury, 26 of hymenal membrane, 261-268 brain, in shaken baby syndrome, 48 of vagina, 260-261 Attachment of vaginal vestibule, 261 foster care and, 600 Ancillary study in postmortem examination, 780 intimate partner violence and, 644

1092 Index

maltreatment affecting, 358 as evidence, 267, 278, 778, 876, 880 psychological maltreatment and, 327-328 recommendations, 702-703, 828 Attention deficit/hyperactivity disorder, 369t-370t Behavior Attention-seeking behavior, 400-401 antisocial, 373 Attitude indicating abuse, 478-482 as barrier to collaboration, 918t, 925 of infant, 347 toward abuse, 723-724 of preschooler, 347 Audio recording of examination, 248 risk-taking, 369 Authority of religious leader, 542 sex abuse indicated by, 212 Autobiographical memory, 347-348 sexual, 352-354 Autopsy, forensic, 778-779 of sexually abused child, 231 Avulsion of toddler, 347 in straddle injury and, 271f Behavior modification as motive for toxic ingestion, 118, of tooth, 91-92 123-124 Awareness of abuse by nonabusive partner, 746 Behavioral disorder, 416 Axis, hypothalamic-pituitary-adrenal, 379 Behavioral therapy, cognitive, 381-382 Axonal injury Benzodiazepine poisoning, 120t, 126t lethal, 787 Best Practices Manual: A Guideline to Establishing a Children’s in shaken baby syndrome, 46-47, 788-789 Advocacy Center Program, 930 Axonal retraction ball, 47 Beta-adrenergic blocking agent, 382 Azithromycin, 294t, 295, 299 Beta-amyloid precursor protein, 787 Betrayal, 438-439 Bias in expert testimony, 718-719 B Bibliotherapy, 491, 492t ß-adrenergic blocking agent, 382 Bichloroacetic acid, 306t Baby bottle tooth decay, 99 Bidirectional relationship Background record check of school personnel, 474 development and, 344-345 Bacterial infection in middle childhood, 348 causing vulvovaginitis, 291t Bilateral fracture of skull, 40 sexually transmitted, 292-299 Biological factors in cycle of violence, 652 chancroid, 299, 304 Biological evidence, 861-916. See also DNA evidence Chlamydia trachomatis, 293-295 Biopsy in lymphogranuloma venereum, 307 genital mycoplasma, 298-299 Birth injury, 31, 50t, 52 gonorrhea, 292-293 Birthmark, 66t granuloma inguinale, 299 Bisacodyl poisoning, 128t lymphogranuloma venereum, 299 Bite injury syphilis, 296-297 handling of, 95-97 trichomoniasis, 298 pattern of, 783 vaginosis, 294, 297-298 Black eye, 74f Bacterial injection, 130t raccoon eye vs., 27 Ball, axonal retraction, 47 Black pepper, poisoning with, 129t Barbiturate poisoning, 125t-126t Barrier Bladder, imaging of, 29 to disclosure of sexual abuse, 729t Bleeding. See Hemorrhage to healthcare for foster child, 601-602 Bleeding diathesis, 139t to screening for intimate partner violence, 629 Bleeding disorder, 52 Base rate of psychological symptom, 417 Bleeding with first intercourse, 267 Battered child syndrome, 219, 716, 737, 766 Blocking software for Internet, 525 definition of, 579 Blood medical awareness of, 1006 collection of, 858, 874 Battered Child Syndrome, The, 113, 559 as evidence, 854 Battering oronasal, 792 during pregnancy, 581 postmortem drainage of, 781-782 head injury from, 580 postmortem study of, 780-781 intimate partner violence versus, 640-641 Blood count in failure to thrive, 200 psychological maltreatment and, 329 Blood type, 861 Bedding Blunt trauma

1093 Child Maltreatment—A Clinical Guide

head injury from, 38-41 postmortem examination of, 785-787 C Caffeine poisoning, 130t pattern of, 783-785 Caffey’s disease, 32-33 in shaken baby syndrome, 787-790 CAGE screening tool, 1085 Boardman, Helen, 1006 Caida de mollera, 566, 582 Body, postmortem examination of Calymmatobacterium granulomatosis, 299 gross external, 779 CANWG. See National Institutes of Health Child Abuse and internal, 779-780. See also Death, cause of Neglect Working Group Body integrity, 436-437 Cao gio, 67, 68, 558t, 566 Body outline drawing, 457-459 CAPS, 430 Bone, lytic lesion of, 29 Caput succedaneum, 38-39 Bone age, 200 Carbon monoxide poisoning, 130t Bone scan, 15 Card, RADAR, 637 Bone scintigraphy, spinal, 21 Cardiac injury, 104 Bony thoracic trauma, 22 Cardiopulmonary resuscitation, 22, 44, 85, 104 Borderline personality disorder Career Development Awards for Child Abuse and Neglect psychological maltreatment and, 329 Research, 994-995 Career development in research, 993-995 sexual abuse related to, 377, 378 Caregiver Bowel injury, 29-30 in Munchausen syndrome by proxy, 396-397, 400-402 Brace, Charles Loring, 1005 physical neglect and, 174 Bradycardia, drug-related, 138t psychopathology of, in chemical abuse, 118-121 Brain of sexually abused child, interview with, 230-232 age-related changes in, 346t Caries, bottle, 99 intracranial hemorrhage and, 787 Case planning, 664t maltreatment affecting, 358 Case study in psychophysiological assessment, 430-431 of chemical abuse, 119-121, 124 Brain atrophy, 48, 52 of drawing in therapy, 456-457 Brain injury of family abduction, 617-618 abuse causing, 33, 579 of Internet contact, 514-515 asphyxiation causing, 580 of lack of enjoyment, 489-490 postmortem examination of, 786 of methamphetamine poisoning, 134 in shaken baby syndrome, 52, 788 of multidisciplinary team, 917 Bright Future: Guidelines for Health Supervision of Infants, of Munchausen syndrome by proxy, 395 Children, and Adolescents, 1063-1064 of overly helpful child, 487 Bronfenbrenner’s ecological approach to development, 345f of phencyclidine poisoning, 134 of poisoning, 133 Bruise of proving timing of injury, 744 asking child about, 412-413 of sexual abuse, 282-284 cold instruments and, 69-72 of shaken baby syndrome, 42 injury patterns of, 67-69 of unintentional ingestion, 141-144 as manifestation of injury, 64-67 of water intoxication, 141 overview of, 63-64 Castor oil poisoning, 128t postmortem examination of, 786, 796-797 Catholic Church timing of injury and, 742 “forgive and forget” cliché and, 545 Bundy, Ted, 415 settlements against, 539-540 Burn injury, 72-78, 580-581 Causation, alternative theories of, 743-744 diagnosis of, 77 Cause of death, 704-705 differential diagnosis of, 74, 77 Caustic ingestion educating of judge and jury about, 737 poisoning with, 128t examination of, 77-79 unintentional, 135, 137t oral, 95 Cefixime, 294t postmortem examination of, 793-794 Ceftriaxone, 294t types of, 72-78 Center for Environmental Health and Injury Control, 579 Buttocks, burn on, 74, 76f, 78 Centers for Disease Control and Prevention on disabled child, 579 Buttocks separation test, 269-270 on HIV infection, 300-301

1094 Index

on sexually transmitted disease in abused child, 292t Child Maltreatment Interview Schedule, 431 Cephalhematoma, 27, 38-39 Child molester, profile of, 210-211 in skull fracture, 39-40 Child pornography. See Pornography Cerebral edema Child protection law, 1004 imaging of, 25 Child protective court proceeding, 764 in shaken baby syndrome, 47 Child protective services. See also Child welfare system Cerebral infarct, 48 changing role of, 4-5 Cerebral palsy, 354, 579, 597 cooperation with other agencies by, 926-927 Certainty, reasonable, 716 data from, 2-3 Cervical injury, 48 decision making by, 920 Chain of evidence, 858 establishment of, 1 in sexual assault, 874-875 failure to thrive and, 202 Chancroid, 299 false allegations of sexual abuse and, 216 Character testimony, 747 goals and mandate of, 919 Chat room, 514-517, 525-526, 535-536 identification of abuse and, 419 Checklist incidence of neglect and, 163-165 preliminary investigative, 698-701 interagency coordination and, 927 for psychological assessment, 429-431 law enforcement collaboration with, 663-664 verbal evidence, 712t law enforcement support of, 661 Chemical abuse, 113-152 neglect and, threshold of, 167 definition of, 115 number of reports to, 2 epidemiology of, 115-117 process of, 664t historical awareness of, 113-114 reporting by school and, 468-469 intentional ingestion as, 117-130 roles and responsibilities of, 922t caregiver psychopathology in, 118-121 Child psychiatrist, 384-385 as discipline, 123 Child sexual abuse accommodation syndrome, 211-212, 421 to modify behavior, 123-124 Child Sexual Behavior Inventory, 431 motive for, 117-123 Child snatching. See Abduction, family physical abuse with, 18, 125 Child Welfare League of America routes of, 117 foster care and, 601 sexual abuse with, 121-123 on multi-problem families, 1016 substances used for, 125-130 Child welfare system, 1003-1030. See also Child terminology related to, 114-115 protective services Chicago Orphan’s Asylum, 1005 battered child syndrome and, 1006 Chief complaint, 777 child protection laws and, 1004 Child community partnerships in, 1019 defined, 114 courts and, 1021-1022 intimate partner violence affecting, 628-629 current climate of, 1024-1026 lack of evidence in, 855 early history of, 1003-1004 Child abuse, definition of, 3. See also Maltreatment goals and mandate of, 919 Child abuse and forensic pediatrics fellowship, 959-963 healthcare and, 1022 Child Abuse and Neglect Working Group, 7 higher education and, 1021 Child Abuse and Treatment Act Amendments, 171 how system works, 1008-1009 Child Abuse Physician Leadership Conference, 954 interagency partnerships in, 1013-1019 Child Abuse Prevention and Treatment Act, 559, 567, 1007 on child maltreatment, 1013 Child advocacy center, 730 on foster care, 1014-1016 sexual abuse and, 214 on multiple-problem families, 1016 Child advocate, 923t obstacles to, 1017-1019 Child and Family Services Review, for 1012-1013 on service delivery system, 1016 Child Behavior Checklist, 431 law enforcement and, 1021 foster care and, 599 legislative mandates in, 1007-1009 Child development. See Development national awareness of maltreatment and, 1005-1006 Child Dissociative Checklist, 429 orphanages and, 1004-1005 Child Dissociative Problem Checklist, 429 outcomes in, 1009-1013 Child endangerment, 132-133 child and family service review and, 1012-1013 Child fatality review program, 702-703 conformity of states in, 1014t Child maltreatment. See Maltreatment indicators of, 1014t

1095 Child Maltreatment—A Clinical Guide

managed care and, 1009-1010 in differential diagnosis of abuse, 32-33 model development and, 1010 Cocaine poisoning, 125t Philadelphia outcome measures project of, 1010-1012 Code of ethics of National Association of Social Workers, systemic factors and, 1015t 1033-1034 schools and, 1020-1021 Codeine poisoning, 126t social service system and, 1019-1020 CODIS system, 865-869, 879-880 workforce issues in, 1022-1024 Coercive question, 243t Child-focused intervention, 1043-1045 Cognitive behavioral therapy, 381-382 Childnet, 520 for sexual abuse, 217 Children’s Advocacy Centers, 930-932 Cognitive development Children’s Aid Society, 1005 age-related changes in, 346t Children’s Attributions and Perceptions Scale, 430 maltreatment affecting, 350-351 Children’s Impact of Traumatic Events Scale-Revised, 431 in middle childhood, 348 Child-resistant cap, 130-132, 137t of preschooler, 347-348 Child-response definition of psychological maltreatment, 316 psychological maltreatment affecting, 328-329 Child’s-eye view of sexual abuse, 235 sexual abuse interview and, 235-237 Chlamydia trachomatis, 293-295 Cognitive interview model, 239 conjunctivitis in, 84 Coining, 68f, 566 lymphogranuloma venereum caused by, 299 Coitus, vulvar, 267 prophylaxis for, 294 pattern of injury with, 273 Chloral hydrate, 126t, 138t Cold medication, poisoning with, 127t Chlorpromazine, 126t, 138t Collaboration, interdisciplinary Chlorthalidone, 128t barriers to, 918-925 Choking, 793, 820t interagency, 928-931 Christian Science, 190, 193, 541 law enforcement and, 663-667 Chromatography, 148t need for, 917-918 Chronic injury, 742 preliminary investigative checklist for, 698-701 Chronosystem, 162 roles and responsibilities in, 922-924 Collaborative investigation, 5, 663-665 Church. See Religious institution Collection of evidence, 278, 853-858 Chylothorax, 22, 104 in bite injury, 96-98 Cigarette burn, 66f, 74, 76f, 84t chain of custody for, 858 Circumcision, female, 559 indications for, 856 Circumstantial evidence, 724-725 overview of, 853-856, 871-875 Civil law on family abduction, 609 procedure for, 856-858 Civil liability, immunity from, 468 Collector of pornography on Internet, 512-513 Civil versus criminal trial, 764, 765t prosecution of, 520-522 Clarifying question, 244 Colon, imaging of, 30 Clavicular fracture Color differential diagnosis of, 31 of bruise, 65 imaging of, 21 in drawings, 452-455 Clergy, self-care by, 548-549 Coma, drug-related, 138t Client focus as obstacle to partnership, 1017-1018 Combating Paedophile Information Networks in Europe Clinical evaluation Project, 519 documentation of, 280 Combined DNA index system, 865-869 pretrial, 761-762 cold hits and, 879-880 Clonidine Comfort issues in sexual abuse interview, 237-238 poisoning with, 125 Committee on Child Abuse and Neglect, 215 for post-traumatic stress disorder, 382 Commotio cordis, 104 Closed-circuit television, child testifying via, 733-734 Communication Closed-head injury, 788 foster care and, 601, 604 Closing argument in court, 753-754 intimate partner violence and, 643-644 Closure of interview, 246-247 between investigators and criminalists, 880-881 Clothing as evidence, 216, 267, 278, 678, 857, 869 maltreatment affecting, 351-352 Clothing documentation form, 901-902 nonverbal, 671-672 Coagulopathy, 66 privileged, 713-715 abuse-related head injury vs., 52, 85 school and, 473

1096 Index

teaching of, 486-487 Contusion Community abdominal, 790-791 child welfare and, 1019 hepatic, 28 curriculum related to, 962t pulmonary, 22, 104, 105f faith, 539-555. See also Religious institution resuscitation attempt causing, 797 prevention and, 1065-1066, 1072-1073 in shaken baby syndrome, 789 Community-based program for psychological maltreatment Convicted offender database, 865-867 prevention, 332 Cooking oil, poisoning with, 129t Competence, cultural, 568-569 Cooperation Complementary and alternative medicine, 567 of child, for evidence collection, 871-872 death of child and, 795 interagency, 926-927 Complete blood count, 200 Coordination, interagency, 927-928 Compliant child victim, 523 COPINE Project, 519 Computed tomography Coping skills, 488-489 of abdominal trauma, 30 Cord, vocal, paralysis of, 580 for neuroimaging, 27 Corneal injury, 84 overview of, 15 Corporal punishment of pancreas, 28-29 religion advocating, 546-547 in shaken baby syndrome, 45, 48 in school, 471-473, 564-565 of skull fracture, 26 Corroboration of child’s disclosure, 731-732 of subarachnoid hemorrhage, 24-25 Corruption, 317, 320t of thoracoabdominal injury, 108-109 Cortical hyperostosis, 32-33 Computer, access to Internet and, 505-512 Cortisol, 379 Computer skills, 506 Co-sleeping, 793, 828 Computing, forensic, in prosecution of pornography, 521-522 Counseling, psychological, 331-332 Conceptual model of neglect, 162-163 Coup-contrecoup effect, 86 Conduct disorder, 375t, 376 Court. See also Prosecution Confidentiality abduction prevention by, 621-622 drawings and, 460-461 child welfare and, 1021-1022 as legal issue, 713-715 curriculum related to, 959t in religious institutions, 540 drawing as evidence in, 462 in screening, 1070 interagency coordination and, 927 Conflict in multidisciplinary investigation, 666-667 juvenile, 919 Conflict Tactics Scale, 560-561 law enforcement and, 669 intimate partner violence and, 641, 646 Confrontation skills, 488-489 persuasion in, 751-754 Confusion as response to abduction, 619t preparation for, 763-764 Congenital disorder preparing child for, 420-421, 732-734 failure to thrive and, 198 sexual abuse case and, 725-736 insensitivity to pain as, 32 Court-ordered examination, 715 syphilis, 296-297 Crack cocaine, 134-135 in differential diagnosis of abuse, 32-33 Cranial injury, 15 Congregation, religious, education for, 546-547 Craniocerebral blunt trauma, 788 Congregational safeguards, 550 Craniofacial injury Conjunctiva, 84 external, 38-39 Consent imaging of, 23-27 drawings and, 461 Creatine phosphokinase, 141 to release confidential information, 714, 719 Crescentic hymenal orifice, 263f Consequences of abuse Crime scene developmental, 356-359 evidence in, 856-858 increased attention to, 8 law enforcement search of, 676-679 Consultant, 740 in medicolegal evaluation of death, 778 Contact burn, 74-76 preservation, 669 Contact head injury, 787 Criminal justice, 724 Context, social, 352 Criminal negligence, 745 Continuity of development, 344 Criminal prosecution. See Prosecution Control in interdisciplinary team, 924 Criminal versus civil trial, 764

1097 Child Maltreatment—A Clinical Guide

Criminalist, 880 Cyanoacrylate poisoning, 128t Criminalization of family abduction, 609, 611-616 Cyber Crimes Center, 519 Critical thinking skills, 1038-1039 CyberTipline, 519 Criticism, abusive, 413 Cycle of violence, 646-652 Cross-cultural study, 565-568 biologic and genetic factors in, 652 Cross-examination child maltreatment in, 647-649 of defense medical witness, 748-751 intimate partner violence in, 648-650 of expert witness, 717, 768 mechanism of, 651-652 in physical abuse case, 746-748 research on, 650-651 Crush, straddle injury and, 271f Cystitis, honeymoon, 273 Crushing of vertebra, 580 Cryotherapy for genital warts, 307t CSAAS, 211-212, 421 D CTS. See Conflict Tactics Scale Dangerous client, warning about, 715 Cultural competence, 568-569 Data Cultural essentialism, 565 on abuse by clergy, 539-540 Cultural issues, 557-572 medical examiner’s interpretation of, 781-785 corporal punishment as, 564-565 Database cross-cultural study of, 565-568 cast-to-case cold hits and, 879-880 definitions in, 557-558 convicted offender, 865-867 incidence of maltreatment and, 560 cost of, 878-879 in intimate partner violence, 563-564, 644 Dating of injury maltreatment and, 558-559 in shaken baby syndrome, 48-49 in psychological maltreatment, 318, 321 skeletal, 18-19 race and ethnicity as, 560-563 Daubert v Merrill Dow Pharmaceuticals, 769 religion and sexuality as, 544 Day treatment program, 381 Cultural pluralism, 568 Day-long training approach, 968-972 Culture, bacterial Death Chlamydia trachomatis, 295 cause of Neisseria gonorrhoeae, 293 abdominal injury as, 105-106 Cupping, 566 anterior chest trauma as, 104 Curling iron burn, 74, 76f blunt force as, 790-791 Curriculum blunt head trauma as, 785-786 Growing Kids God’s Way, 546 burn injury as, 793-794 pediatric residency, 943, 952-960 choking as, 793 for child abuse and forensic pediatrics fellowship, determination of, 704-705, 774-775 960-963 intra-abdominal injury as, 790 day-long approach to, 968-972 intracranial hemorrhage as, 787 on evaluation and management, 953t intrathoracic injury as, 790 goal of, 953t mechanical asphyxia as, 792 non–rotation-based longitudinal approach to, 963- Munchausen syndrome by proxy as, 796 968 neglect as, 794-795 on normal versus abnormal, 955-956 overlying, 792 overview of, 967f physical abuse as, 773-774 on pediatrician’s role, 953t poisoning as, 793 on prevention, 954t, 955t shaking as, 787-790 on referral, 956-957 skull fracture as, 786-787 on signs and symptoms, 956 smothering as, 792 summary of, 957-959 strangulation as, 792 for practicing physician, 972 thoracoabdominal injury as, 103 for SANE nurse training, 951t-952t underlying, 774-775 Custodian interference. See Abduction, family child fatality review program and, 702-703 Custody, chain of, 874 faith healing and, 547 Custody dispute, 216-217 law enforcement investigation of, 680-681 Customer for Internet pornography, 512-513 medicolegal evaluation of, 776-781 Customs Service, 519 ancillary studies in, 780-781 Cutaneous injury, 958t case history in, 777-778

1098 Index

gross external observation in, 779 effects of, 482-483 investigation components of, 777 in investigation and prosecution of cases, 350 investigation process in, 777 in psychological response, 410 physical examination in, 778 sexual behavior and, 352-354 postmortem examination in, 778-779 social development and, 351-352 soft tissue and organ examination in, 779-780 special needs child and, 354-356 neglect and, 164, 794 milestones of, 345-349 organ transplantation and, 798-799 in adolescence, 346t, 348-349 Debriefing, drawing tasks for, 458 in infancy and toddlerhood, 345, 346t, 347 Debris, 679, 857-858 in middle childhood, 346t, 348 Decay, tooth, bottle-related, 99 in preschool period, 346t, 347-348 Decision making nature of, 343-345 by social worker, 1034-1038 as obstacle to partnership, 1017 in various disciplines, 920 of sexual behavior, 353 Declaration, hearsay, 762 Developmental factors Defendant, confronting of, 746-748 in failure to thrive, 199 Defense post-traumatic stress disorder and, 417 expert witness confronted by, 739 in sexual abuse interview, 235-237 in physical abuse case, 746-751 in sexual abuse treatment, 218 against pornography prosecution, 521-522 Diagnosis as hearsay exception, 708-709 against sexual abuse prosecution, 735-736 Diagnostic aid, drawing as, 449-450 Degradation, 317, 320t Diagnostic and Statistical Manual of Mental Disorders, 367 Dehydration, 794-795 on malingering by proxy, 120 Denial on Munchausen syndrome by proxy, 396 of care, 795 on psychological maltreatment, 328 by clergy, 542 Diagnostic opinion in court testimony, 762 of sexual abuse, 232-233 Diagnostic radiograph, 14 Dental neglect, 98-99 Diagnostic separation, 404-405 Dentist as mandated reporter, 99-101 Dialogue, negative mental, 434-435 Denver Developmental Screening Tool, 598 Diaphyseal fracture, 17, 18f Department of Health and Human Services, 928-929 of radius and ulna, 20 Child and Family Service Review, 1012-1013 tibial, 19 Department of Justice, 519, 880 Diarrhea Office for Victims of Crime, 551 case studies of, 142, 144 Deposition, 764 drug-related, 139t Depression Diet, failure to thrive and, 197 criteria for, 371t, 374 Diffuse axonal injury, 46-47, 788-789 neglect related to, 168 Digital penetration sexual abuse related to, 217-218, 377 anal, 275 Deprivation vaginal, 272-273 of calories, 174 Digital rectal examination, 269, 271 emotional, 583 Dihydrocodeine poisoning, 126 maternal, 195 Dilation of pupil, 84 of water, 129t, 139t, 141-142 Dilution of formula, 131-132 Descemet’s membrane, 84 Diphenhydramine poisoning, 126 Destruction of property, 375t Disabled child, 573-594 Details in sexual abuse disclosure, 233-234 asphyxiation and, 580 Detection of drug abuse, 146-149 brain damage in, 579 Deterrence as law enforcement role, 661 burns and, 580-581 Development cause and effect relationship and, 583-584 artistic, 451-454 development of, 354-357 contexts of, 345 fetal exposure to drugs causing, 581 of foster child, 598-599 firearm injury and, 582 maltreatment and, 349-359 folk medicine and, 582 cognitive development and, 350-351 head injury causing, 54-55 consequences of, 357-359 head injury of, 579-580

1099 Child Maltreatment—A Clinical Guide

incidence of, 573-574 restriction fragment length polymorphism and, 863-864 literature on, 577t serological testing and, 861-862 long-term sequelae of maltreatment and, 583 shortage of laboratory resources for, 878-879 Munchausen syndrome by proxy and, 582 DNA index system, 865-869, 879-880 national data sets on, 579 Dobson, James, 546 near drowning and, 580 Documentation neglect of, 577-578, 583 of autopsy, 774t, 778-779 psychological injury and, 582 of bite injury, 96 reporting institutional abuse of, 470-471 of child’s exact words, 710, 712t risk factors for, 354-356, 574-576 curriculum related to, 959t, 965t scope of abuse of, 576-577 of DNA evidence, 875 spinal cord injury of, 580 of examination of suspect, 905-909 violence during pregnancy and, 581-582 in identification of abuse, 419-420 Discipline of interview with sexually abused child, 247-248 cycle of violence and, 651-652 of law enforcement investigation, 681 as motive for toxic ingestion, 123 of perpetrator identification, 709 in school, 471-473 preliminary rape case information, 912-913 screening questions about, 1089-1090 prepubescent sexual assault information, 898-900 Disclosure SART clothing, 901-902 of confidential information, 714-715 of sexual abuse, 215, 279-281 leading to punishment, 710 Domestic violence. See Intimate partner violence of sexual abuse, 211-212, 232-235, 516 Donation, organ, 798-799 barriers to, 729t Donovanosis, 299 prosecution of case and, 725-726 Doubt, reasonable, 724-725 Disk herniation, 20-21 Doxycycline, 294t, 295, 299, 310t Dislocation, elbow, 20 DQA1 test, 864 Displacement of tooth, 92-93 Drainage of blood, 781-782 Dispute, custody, 216-217 Drawing, 449-465 Disseminated herpes infection, 304 as admissible evidence, 462 Dissociation as assessment tool, 449-450 explaining to child, 434 indicators of maltreatment in, 452, 455-456 symptoms of, 429 materials for, 451 Dissociative Experiences Scale, 429 normal artistic development and, 451-454 Dissociative identity disorder, 423 in treatment, 450-451, 456-460 Distension, gastric, 29 Drowning, near miss, 580 Diuretic, poisoning with, 128t Drug. See also Unintentional ingestion Diversity of polymerase chain reaction tests, 864-865 poisoning with, 125-128 Divorce, 216, 609, 621t to produce illness in child, 120 DNA evidence, 861-916 Drug abuse case studies of, 869-871, 882-897 child’s response to, 412 case-to-case cold hits using, 879-880 detection of, 146-149 collection of, 871-875 neglect and, 168 cooperation of child for, 871-872 in pregnancy, 581 examination and, 873-875 psychological maltreatment and, 325 communication about, 880-881 Drug screen convicted offender database of, 865-867 postmortem, 780 documentation for, 898-913 urine, 146 first use of, 862-863 Drug therapy for post-traumatic stress disorder, 382-383 handling of, 869-871 Drug-endangered children program, 134 lack of training about, 876 D1S80 test, 864 law enforcement investigation and, 875-877 Duodenal hematoma, 790 polymerase chain reaction and, 864-865 Duodenum, 29-30 in prosecution of sexual abuse, 728 Dwarfism, psychosocial, 197 reexamination of unsolved cases and, 877-878 Dysfunctional family, 160t-161t resource crisis related to, 867-869 Dysrhythmia, drug-related, 138t resource management and, 880 Dysuria, postfondling, 268, 273, 283

1100 Index

safe, 1083-1084 E Enzyme Eating disorder, 377-378, 411 liver, 141 Ecchymosis of eyelid, 84t muscle, 141 Ecological approach pancreas, 28, 106 to development, 345 in seminal fluid, 853-854 to neglect, 162-163 Enzyme multiplied immunoassay technique, 148t Ecology, decision-making, 1035 Ephedrine, poisoning with, 127t Edema EPIC-SCAN program, 972 cerebral, 25 Epidemiology of eyelid, 83 cultural aspects and, 559 Educating Physicians in Their Communities model, 972 of maltreatment, 1-3 Education. See also Curriculum; Training of Munchausen syndrome by proxy, 399 child welfare and, 1021 of neglect, 163-165 for clergy, 546 of psychological maltreatment, 321 by expert witness, 738 of sexual abuse, 209-210 of judge and jury, 737-738 of thoracoabdominal injury, 103 prevention of abuse in school and, 473-474 Epidural hematoma Educational Guidelines for Residency Training in General imaging of, 24 Pediatrics of Ambulatory Pediatric Association, 952-960 postmortem examination of, 787 Educational neglect, 155t, 176 presentation of, 40 Egocentricity of preschooler, 347 Epsom salts, 128t, 144 Ejaculation, 853 Erysipelas, 74, 76f Elbow dislocation, 20 Erythromycin, 294t, 299 Electrolyte, 116t, 136, 140, 144 Esophagus, 29 Electronic media, 505-510 Essentialism, cultural, 565 Elmer, Elizabeth, 1006 Estrogen, hymen and, 262, 265f, 266-267 Emergency, confidential information and, 715 Ethanol poisoning, 129t Emergency department nurse, 949 Ethics Emergency medicine fellow, pediatric, 946-947 child’s drawings and, 460-462 Emergency medicine resident, 947-948 confidentiality and, 713 Emetine, 141 dentistry and, 99-100 EMIT, 148t of National Association of Social Workers, 1033-1034 Emotional abuse, 315-340. See also Psychological maltreatment Ethnicity, 560-563 Emotional development, 346t Ethylene glycol poisoning, 128t Emotional factors Evaluation in failure to thrive, 196 of sexual abuse victim, 214, 253-288. See also Sexual in sexual abuse interview, 237-238 abuse, medical evaluation of Emotional neglect, 154t-155t Evans, W.A., 1006 Empirically supported intervention, 1042-1043 Evidence Encephalomalacia, 46t, 48f circumstantial, 724-725 Encephalopathy, hypoxic-ischemic, 580 in civil versus criminal court, 764 Encoding, 350-351 collection of, 278, 853-858 Encopresis, 269 in bite injury, 96-98 Endangerment, child, poisoning and, 132, 133-134 chain of custody for, 858 Enforcement indications for, 856 law. See Law enforcement DNA, 861-916. See also DNA evidence by religious institution, 548 drawing as, 462 Engagement stage of abuse, 516 law enforcement handling of, 670t ENHANCE, 598 in prosecution Enteritis, 310t of physical abuse, 751-752 Environment of sexual abuse case, 726-727 death from neglect and, 795 of sexual contact, 253, 267 disability and, 584-585 trace, 779 intimate partner violence and, 644 verbal, 712t poisoning and, 132-134 Evidence-based practice of social worker, 1039-1041 risk to disabled child and, 575-576 Exaggeration in Munchausen syndrome by proxy, 401

1101 Child Maltreatment—A Clinical Guide

Examination, physical. See Physical examination in chemical abuse, 118-121 Exception, hearsay, 708-710, 727-728, 730 death of child and, 796 Excited utterance, 708 injury as, 66t Exemption, religious, to state statutes, 189-193 Munchausen syndrome by proxy as, 396. See also Exosystem, 162, 345 Munchausen syndrome by proxy Expert testimony, 715-719, 761-772 Factual vs. legal issue, 766 bias in, 718-719 Failure to thrive, 173, 195-207 in civil versus criminal court, 764 curriculum related to, 958t cross-examination of, 717 drug ingestion causing, 139 curriculum related to, 959 etiology of, 197-198 for defense, 748-751 evaluation and diagnosis of, 198-201 doubts about, 717 intervention for, 178 form of, 716 outcome of, 203 impeachment of, 718 overview of, 195 irresponsible, 768-771 psychological maltreatment and, 328 legal versus medical proof in, 765 risk factors for, 196-197 in Munchausen syndrome by proxy, 406 treatment of, 201-203 opposing counsel tactics for, 768 Faith community, 539-555. See also Religious institution preparation for, 715 Faith healing, death related to, 547 pretrial preparation for, 761-764 Fall, 70 in prosecution of physical abuse, 736-740 abdominal injury from, 107 qualifications for, 715, 766, 770 abuse-related head injury vs., 50-52 in sexual abuse case, 728 skull fracture from, 40 successful, 767-768 Fallen fontanelle, 566, 582 undermining of, 717-718 False accusation, defense claim of, 735 Exploitation False allegation of abuse, 425-428 Internet and, 510, 519, 523 in school, 473 photographic, 678 sexual, 216-217 Exposure False memory syndrome, 425 on Internet, 511 Falsification in Munchausen syndrome by proxy, 396 to sexually explicit material, 415 Family. See also Family violence Expression identification of abuse and, 418-419 artistic, 452 prevention of abuse and, 1065 verbal, 437-438 risk to disabled child and, 575-576 External craniofacial injury, 38-39 schools working with, 476-477 External examination of body, 779 therapist working with, 439-440 Externalization of problem, 329-330 Family abduction, 609-623. See also Abduction, family Extra-abdominal injury, 108 Family assessment, 664t Extragenital trauma, 275 Family court, 919 Extremity Family dynamics, 323 injury to, 17-18 Family dysfunction postmortem examination of, 779, 780, 790 descriptions of, 160t-161t Eye, 83-89 in failure to thrive, 196 anatomy of, 83f Family history in failure to thrive, 198 conjunctival disorder and, 84 Family medicine resident, 948 cornea, anterior chamber, and lens of, 84 Family Preservation and Family Support Program, 1008 eyelid and periorbital abnormality of, 83-84 Family resource scale, 1029-1030 imaging of injury to, 27 Family therapy, 422-423 retinal injury to, 85-87 Family violence, 639-658 in shaken baby syndrome, 789-790 child maltreatment and, 645-646 Eyelid, 84 cycle of, 646-652 intimate partner violence and, 639-645 Fantasy defense, 735 F Fatality. See Death Fabrication in Munchausen syndrome by proxy, 401 Fatality review program, 702-703 Facial injury, 38, 786, 792 Fear, dispelling of, 433-434 Factitious disorder Fecal analysis, 144

1102 Index

Federal agency for fighting Internet crime, 519-520 fracture of, 19 Federal Bureau of Investigation, 519 Force in skull fracture, 786-787 Federal Family Educational Rights and Privacy Act, 469 Forced feeding, 95 Federal funding of research, 979-1002. See also National Foreign debris, 857-858 Institutes of Health Child Abuse and Neglect Working Foreign producer of pornography, 514 Group Forensic computing in prosecution of pornography, 521-522 Federal missing child legislation, 615t-616t Forensic evidence, 853-859. See also Evidence Federal poverty line, 562 Forensic interview in sexual abuse, 730-731 Feeding, infant, oral injury from, 95 Forensic odontologist, 96 Feeling X-Ray drawing, 457-459 Forensic pediatrics Fellow, pediatric emergency medicine, 946-947 curriculum for, 960t-963t Female skills list for, 963t genital anatomy of, 260-268 Forensic postmortem examination, 778-779 of hymenal membrane, 261-268 Forensic videotaping, 419-420 of vagina, 260-261 Forensically defensible questioning, 710-712 of vaginal vestibule, 261 Forensics in sexual abuse interview, 229 growth chart for, 200 Form religious view of, 544 cause and manner of death, 704-705 Female circumcision, 559 child fatality review, 837 Femoral fracture, 19 forensic lab services, 913 Fetal alcohol syndrome, 581 preliminary rape case, 912-913 Fetus, violence during pregnancy affecting, 581-582 prepubescent sexual assault, 898-900 Fever, drug-related, 138t SART clothing documentation, 901-902 Fibular fracture, 19 sexual assault, suspect examination, 905-909 Fimbriated hymenal edge, 266f sudden unexplained infant death, 847-852 Financial issues in foster care, 595, 603 Formal Elements Art Therapy Scale, 450 Fire, child’s drawing of, 455-457 Formula, dilution of, 131-132 Firearm injury, 582 Foster care, 595-607 First-degree burn, 77, 78f definition of, 595 First responder developmental needs in, 598-599 DNA evidence and, 876 disability and, 583-584 inquiry of child by, 729-730 healthcare programs for, 603-604 Five Points Center, 1005 healthcare recommendations for, 600-603 Flame burn, 74, 76f, 78f interagency partnerships on, 1015-1016 Fluid mental health issues in, 599-600 seminal physical health needs in, 596-598 collection of, 778 race and, 561 as forensic evidence, 853-856 types of, 595-596 testing for, 853-854 Fourth Amendment of Constitution, 677 vitreous, 780-781 Fracture Flunitrazepam dating of, 18-19 to facilitate sexual abuse, 122 educating of judge and jury about, 737 poisoning with, 125t femur, 19 Fluorescent treponemal antibody absorption test, 297 fibula, 19 Fluoxetine, 382 foot, 19 Focused question, 243t hand, 20 Folk medicine humeral shaft, 19-20 danger of, 582 imaging of, 16-23 death causing, 797 postmortem examination of, 782, 786-787, 790, 791f skin manifestations of, 66t rib, 31, 104, 105f Follow-up by therapist, 439-440 in shaken baby syndrome, 44-45 Follow-up investigation, 669t skull, 39-40 Fondling, genital, 272-273 imaging of, 26 Fontanelle, fallen, 566, 582 postmortem examination of, 786-787 Food, abuse related to, 411 spinal, 20-23, 579 Foot sternal, 104 burn on, 76f tibia, 19

1103 Child Maltreatment—A Clinical Guide

of tooth, 93 Granuloma inguinale, 299 type of, 16-17 Grooming of victim via Internet, 516 Fracture/separation, humeral, 20 Gross external observation of body, 779 Framing defense, 735-736 Group home, 596 Freaking, 275 Group therapy, 422-424 Free running narrative approach to interview, 240-241 with other abused children, 439 Freedom, religious, 568 Growing Kids God’s Way, 546 Frenula, 93-94 Growth chart, 200f Frog-leg position, 258, 259f Growth failure, 195-207. See also Failure to thrive Frustration model of abuse, 575 Growth retardation, intrauterine, 198 Frye v United States, 768-769 Guanfacine, 382 FTA-ABS test for syphilis, 297 Guidance, anticipatory, 1072 Guidelines interview, 668, 671-676 G for reporting sexual abuse, 220t Game, sexual abuse presented as, 414 Guilt as response to abduction, 619t Gamma hydroxybutyrate Gunshot wound, 582 to facilitate sexual abuse, 122-123 poisoning with, 125t Gap H anion, 142-144 Hague Convention on the Civil Aspects of International osmolar, 142 Child Abduction, 612-614, 616t Gas chromatography, 148t Hair Gastric laceration, 790 collection of, 857 Gender, psychological maltreatment and, 322, 330-331 as evidence, 779, 855 General intent, 745 Hand as weapon, 69-70, 73f Generalized anxiety disorder, 372t Hand fracture, 20 Genetic factors in cycle of violence, 652 Handgun control, 582 Genetic marker, 854 Hard palate injury, 94-95 Genital fondling, pattern of trauma with, 272-273 Hazard, environmental, 584 Genital herpes, 303-305 Hazardous environment, poisoning in, 133-135 Genital injury, healing of, 276-277 Head injury, 37-62 Genital mycoplasma, 298-299 abuse causing, 579-580 Genitalia, postmortem examination of, 790-791 blunt, 38-40 Genital-to-anal contact, 275 epidural hemorrhage as, 40 Giardia lamblia, 310t external craniofacial, 38-39 Gingival injury, 93 skull fracture as, 39-40 Gingivostomatitis, 304 curriculum related to, 958t Glibenclamide poisoning, 127t Global trends in maltreatment, 585 differential diagnosis of, 49-54 Glucose in hypoglycemia, 136-137 imaging of, 23-27 Glutaric aciduria law enforcement investigation of, 680-681 abuse-related head injury vs., 52 outcome of, 54, 55t in differential diagnosis of abuse, 31 overview of, 37-38 Glutethimide, poisoning with, 126t perpetrators of, 49 Glycoprotein p30, prostatic, 854 postmortem examination of, 785-790 Gonorrhea, 292-293 prevention of, 54, 56 Good faith, 468 rotational, 40-49 Government associated injury with, 44-45 disability and, 584-585 imaging in, 45, 46t funding of research by, 979-1002. See also National intracranial injury in, 45-48 Institutes of Health Child Abuse and Neglect mechanism of injury in, 40-42 Working Group presentation of, 42 poverty and, 563 retinal hemorrhage in, 43-44 religious institutions and, 551 timing of, 48-49 Granulation tissue, 276 Head Start, 179 in fracture, 18 Healed injury, interpretation of, 276-277

1104 Index

Healing Hepatitis B virus infection aging of injury and, 782-783 prophylaxis for, 294t faith, 547 risk factors for, 301 Health, violence affecting, 625-626 Herbal medicine, 127t Health Insurance Portability and Accountability Act, 469 Herniation, disk, 20-21 Health status, 565 Heroin poisoning, 125t Healthcare Herpes simplex virus, 303-305 child welfare and, 1022 clinical presentation of, 303-304 foster care and, 595-608. See also Foster care laboratory findings in, 304 public policy and, 584-585 treatment of, 304-305 Healthcare provider Herpetic whitlow, 304f cooperation with other agencies by, 926-927 Heterochromia, 84 decision making by, 920 High performance liquid chromatography, 149t evaluation of neglect by, 168-170 Hiring of school personnel, 473-475 goals and mandate of, 919 History interagency coordination and, 927 in failure to thrive, 198-199 roles and responsibilities of, 922t in medicolegal evaluation of death, 777-778 testimony by, 766 in sexual abuse examination, 254-255 Hearsay in sexual abuse interview, 227-231 exceptions to, 707-710, 712 of thoracoabdominal injury, 106-107 special circumstance of, 762-763 Home, medical, 601 Hearsay exception, 727-728 Homeless child Heart injury, 104, 108 failure to thrive in, 202 Heavy metal poisoning, 130t sexual abuse and, 483 Helmenthic infection, 291t Homicide, 776. See also Death Helpfulness, 487-488 alternative theories of causation and, 743-744 Hematologic disorder, 66t confronting defendant in, 746-751 Hematoma determining likely perpetrator, 757-759 in duodenal injury, 30, 790 expert testimony in, 736-740 epidural, 24 mechanism of injury and, 741-742 intestinal, 109 nature of injuries in, 740-741 subdural persuasion in, 751-754 imaging of, 23-24 proving identity of perpetrator, 744-746 in skull fracture, 40 timing of injury and, 742-743 subperiosteal, 17 Honeymoon cystitis, 273 Hematuria, 108 Hospital, disabled child abandoned in, 578 Hemophilia, 68f Hospitalism, 195 Hemorrhage Hospitalization of neglected child, 177 epidural, 40 Hot water burn, 74, 75f intra-abdominal, 106 postmortem examination of, 778, 794 intracranial Household chemical poisoning, 128t imaging of, 25 Human bite. See Bite injury postmortem examination of, 787 Human immunodeficiency virus infection of liver, 28 clinical presentation of, 300-301 postmortem examination of, 779, 787 laboratory evaluation of, 301 resuscitation attempt causing, 797 overview of, 299-300 retinal prophylaxis for, 294t differential diagnosis of, 85-86 treatment of, 301-303 in shaken baby syndrome, 43-44 Human papillomavirus, 305-308 scalp, 38 clinical presentation of, 306 in shaken baby syndrome, 789-790 overview of, 305-306 subarachnoid, 24-25 treatment of, 306t-307t, 308 subconjunctival, 84 Human rights, 559 subgaleal, 39 Humeral shaft fracture, 19-20 Hemosiderosis, 84 Hymen Hepatic contusion, 28 anatomy of, 261-268

1105 Child Maltreatment—A Clinical Guide

postmortem examination of, 791 pelvic, 21-22 Hymenal orifice, 260-265 spinal, 20-21 diameter of, 266 sternum, 21 Hyperactivity disorder, 369t-370t thoracic, 22-23 Hyperarousal, 379 tibia and fibula, 19 Hyperextension, spinal, 580 overview of, 13-14 Hyperflexion, spinal, 20-21 in shaken baby syndrome, 45-48 Hypernatremia, 141-142 of thoracoabdominal injury, 108-110 Hyperostosis, infantile cortical, 32 Imiquimod, 306t Hyperphagic short stature, 197-198 Immediate response as law enforcement role, 661 Hyperpigmentation, 779, 796 Immersion burn, 74, 75f Hypersensitivity vasculitis, 66t postmortem examination of, 794 Hypertension, drug-related, 138t Immunity from prosecution for reporting abuse, 468 Hypoglycemia, induced, 136-137, 139-140 Immunoassay, 148t Hyponatremia, 140-141 Impact syndrome, shaken, 40-41, 579, 788. See also Shaken Hypotension, drug-related, 138t baby syndrome Hypothermia Impeachment of expert testimony, 717 drug-related, 138t Impetigo, staphylococcal, 76f, 77 Hypothalamic-pituitary-adrenal axis, 379-380 Impulsivity, 370t Hypothetical question, 716 Inanimate object for anal penetration, 274 Hypoxic-ischemic encephalpathy, 580 Inattention, 369t Incidence of abuse, 560 Income, reporting of abuse and, 561t, 562-563 I Independent living, 596 Iatrogenic injury, fatal, 797 Index system Icterus, 139t combined DNA, 865-867 Idaho v Wright, 763 Exosystem, 162 Identification Indian Child Welfare Act, 1007-1008 of abuse, 418-419 Indicated prevention interventions, 1065 of perpetrator, 709 Indicator of sexual abuse, 212-213 Identity disorder, dissociative, 423 Induction of symptoms in Munchausen syndrome by proxy, Ignoring, 317, 319t 401-402 IINI, 519 Infant Illicit drug abandonment of, 174-176 definition of, 115 blunt head injury to, postmortem examination of, 785-786 in poisoning of child, 125t consequences of maltreatment in, 357-358 Illness of foster child, 596-597 developmental milestones of, 345-347 Imaging, 13-36 differential diagnosis of abuse in, 31-32 of abdominal injury, 27-30 dilution of formula of, 140 of craniofacial injury, 23-27 evidence collection from, 872 in differential diagnosis, 30-33 head injury in, 37 modalities of, 14-16 intrauterine growth retardation in, 198 computed tomography, 15 oral injury to, 95 magnetic resonance imaging, 15-16 physical maltreatment of, 368 nuclear medicine, 14-15 shaken baby syndrome in, 40-49. See also Shaken baby ultrasound, 16 syndrome of musculoskeletal injury, 16-23 Infantile cortical hyperostosis, 32 clavicular, 21 Infantile rickets, 32 date of injury, 18-19 Infarct, cerebral, 48 extremities, 17-18 Infection femoral, 19 causing vulvovaginitis, 291t foot fracture, 19 parasitic, 66t fracture, 16-17 sexually transmitted, 289-313. See also Sexually hands, 20 transmitted disease humeral shaft fracture, 19-20 skin manifestations of, 66t multiple, 18 viral. See Viral infection

1106 Index

Inflammatory mediator, 782 Insight, 491 Information Instability, 411 confidential, 713-715. See also Confidentiality Institutional abuse from expert witness, 716 in religious community, 539-555. See also Religious in interview with sexually abused child, 241-246 institution obtained from child, 5-6 reporting of, 470-471 Information form. See also Form Instrument Informed consent as cause of death, 778 drawings and, 461 pattern of injury and, 783-785 to release confidential information, 714 skin injury from, 69-72 Ingestion Insulin intentional, 114-130. See also Intentional ingestion hypoglycemia and, 136-137, 139 unintentional, 124, 130-149. See also Unintentional poisoning with, 127t ingestion Insurance, lack of, 584 Injury Intake by child protective services, 664t accidental, 274-275 Integrity, body, 436-437 aging of, 782-783 Intent, 745 asking child about, 412-413 Intentional ingestion brain, 579 definition of, 114 burn, 72-78, 580-581, 793-794 motive for, 117-124 curriculum related to, 958t-959t numbers of, 116t drawings indicating, 452, 455-456, 458-459 routes of, 117 expert testimony to prove, 736-740. See also Expert substances used for, 125t-130t testimony gas, 130t firearm, 582 heavy metals, 130t head, 37-62, 580. See also Head injury household chemicals, 128t household products, 128t-129t iatrogenic, 797 illicit drugs, 125t lethal. See Death, cause of nonmedicinal substances, 129t-130t mechanism of, 741-742 pharmaceuticals, 125t-128t medical examiner’s investigation and, 774-775 Interagency collaboration, 928-931 nature of, 740-741 Interagency cooperation, 926-927 oral, 91-102. See also Oral injuries Interagency coordination, 927-928 pattern of Interagency partnership, 1013-1019 extragenital, 275 on child maltreatment, 1013 genital fondling, 272-273 on foster care, 1013-1016 healing or healed, 276-277, 782-783 on multiple-problem families, 1016 labial agglutination, 274, 275f obstacles to, 1017-1019 oral, 95-96 on service delivery system, 1016-1017 in postmortem examination, 782-783, 783-785 Interagency Work Group on Child Abuse and Neglect, 998 thoracoabdominal, 103-106 Intercourse, first, 267 from vaginal penetration, 273 Interdisciplinary collaboration. See also Multidisciplinary from vulvar coitus, 273 team rape trauma syndrome and, 421 barriers to, 918-925 self-inflicted, 66 law enforcement and, 664-667 to skin, 63 need for, 917-918 spinal cord, 20-21, 580 preliminary investigative checklist for, 698-701 straddle injury and, 271f roles and responsibilities in, 922t-924t theories of causation, 743-744 Interference, custodian. See Abduction, family thoracoabdominal, 103-112. See also Thoracoabdominal Interferon, 307t injuries Intergenerational transmission of violence, 646-652 timing of, 48-49, 742-743 Internalization Innocent Images National Initiative, 519 of problem, 329 Insecure attachment, 358, 327-328 restructuring of, 435 Insecurity, 327-328 International abduction, 612-614, 616t Insensitivity to pain, congenital, 32 International Child Abduction Remedies Act, 616t In-service training for school staff, 475-476 International jurisdiction on pornography, 514

1107 Child Maltreatment—A Clinical Guide

International nursing, 950 Intimate partner violence, 625-637, 639-645 International organization, 585 assessment of, 641 International Parental Kidnapping Crime Act, 616t battering vs., 640-641 International study on intimate partner violence, 632 children affected by, 628-629 Internet, 505-537 definition of, 625, 639-640 child sexual offenders using, 514-517 environmental and cultural factors in, 644 to collect pornography, 512-513 failure to thrive and, 202 law enforcement and, 519-524, 530-534 health and, 625-626 to lure victims, 523-524 international studies of, 632 to produce pornography, 513-514, 522-523 Internet resources on, 636 risks related to, 510-512 maltreatment and, 563-564 terminology, 535-537 man as victim of, 631 unsolicited contact via, 517-518 mandated reporting of, 631 usage of, 505-510 parent-child violence and, 644-645 Internet Relay Chat, 514 pediatric studies of, 626, 628 definition of, 536 perpetrator of, 641-642 Internet resources in pregnancy, 581-582 on intimate partner violence, 636 prevalence of, 625, 641 for social worker, 1050 psychological response to, 412 Internet service provider relationship characteristics of, 643-644 blocking software of, 525 screening for, 626-628, 629-631, 637 chat room of, 514 screening questions about, 1086-1088 definition of, 536 theories about, 641 profiles and, 516 victim characteristics of, 642-643 Interpersonal communication in school, 486 Intoxication, water, 129t, 140-141 Intra-abdominal hemorrhage, 106 Interpersonal problem, 368 Intra-abdominal injury, 790 Interpersonal violence, 639-658 Intracranial hemorrhage child maltreatment as, 645-646 imaging of, 25 cycle of, 646-652 postmortem examination of, 787 intimate partner, 639-645 Intracranial injury Interpretation of data by medical examiner, 781-785 abuse-related vs. head injury, 52 Interview chronic sequelae of, 26 curriculum related to, 964t in shaken baby syndrome, 45-48 by law enforcement Intrafamilial perpetrator of sexual abuse, 210 of suspected perpetrator, 674-675 Intraocular hemorrhage, 86 of witness, 673-674 Intrathoracic injury of medical personnel, 727-728 imaging of, 22 in Munchausen syndrome by proxy, 405 postmortem examination of, 790 in preparing child for court, 420-421 Intrauterine growth retardation, 198 protocols for, 730-731 Intravaginal longitudinal septum, 263f of school personnel, 474-475 Investigation of sexually abused child, 227-251 by child protective services, 5, 664t caregiver history in, 230-232 collaborative, 5 developmental considerations in, 235-237 of crime scene disclosure process in, 232-235 by law enforcement, 676-679 documentation of, 247-249 in medicolegal evaluation of death, 778 emotional issues in, 237-238 developmental issues in, 350 by law enforcement, 668, 670-673 follow-up, 669t in medical evaluation, 239-247 by law enforcement, 659-705. See also Law enforcement models for, 238-239 by medical examiner, 773-804. See also Medical overview of, 227-230 examiner of suspect, 734-735 Investigator videotaping of, 419-420 communication with criminalists, 880-881 Intestine roles and responsibilities of, 922-923t intramural hematoma of, 109-110 Ipecac perforation of, 105-106, 107 muscle enzymes and, 141 evaluation of, 109 poisoning, 127t

1108 Index

Iron poisoning, 125t of sexually transmitted disease, 290 Irresponsible medical witness, 748-751 of syphilis, 296-297 Irritability, 138t in thoracoabdominal injury, 108 Isolation of Trichomonas vaginalis infection, 298 as form of psychological maltreatment, 317, 319t of unintentional ingestion, 136 neglect and, 166-167 Laceration, 63 Isopropanol poisoning, 128t of bowel, 790 conjunctival, 84 corneal, 84 J of eyelid, 83, 84t Jacobi, Abraham, 1006 healed, 276 Jeffreys, Dr. Alec, 862 Lamp, Wood’s, 874 Jewish religion, 541 on sexuality, 544 Language Judge, educating of, 737-738 in communication with children, 351-352 Judicial system, DNA testing and, 868-869 of sexual abuse interview, 235-237 Jurisdiction, pornography and, 514 programming, 536 Jury Latino attitude toward abuse, 723-724 health status and, 565 educating of, 737-738 mollera caida and, 566 Justice system Lavage, peritoneal, 108 goals and mandate of, 919 Law medical science and, 724 confidential records and, 713 psychological maltreatment and, 333 on family abduction, 609 Juvenile justice system safe haven, 175-176 goals and mandate of, 919 Law enforcement, 659-705 psychological maltreatment and, 333 child welfare and, 1021 Juvenile sex offender, 211 decision making by, 920 DNA evidence and, 875-877 DNA testing resource crisis and, 868-869 K fatality review program and, 702-703 Kempe, Henry, 1, 1006 forms for Kentucky Baptist Children’s Home, 1004 affidavits and search warrant application, 685-697 Kidnapping. See Abduction, family coroner/medical examiner data, 704-705 Kidney, imaging of, 29 goals and mandate of, 919 Kids in court program, 732 interagency collaboration and, 928-931 Kinky hair disease, 33 interagency cooperation and, 926-927 Knee-chest position, 258, 259f interagency coordination and, 927-928 hymen and, 262f-263f Internet and, 511, 519-524 Knife injury, 63 investigation by, 667-676 Knowing conduct, 745 checklist for, 698-701 of child fatality, 680-681 considerations for, 669t crime scene search in, 676-679 L interview guidelines for, 668, 671-675 Labial agglutination, 274, 275f report of, 681 Labial frenula, 93-94 sample protocol for, 670t Laboratory, DNA, 878-879 special techniques in, 675-676, 677t Laboratory evaluation victim interview in, 671-673 of bacterial vaginosis, 297-298 witness interview in, 673-675 of chlamydial infection, 295 on multidisciplinary team, 664-667 curriculum related to, 965t pornography and, 513-514 of failure to thrive, 198, 200-201 preliminary actions by, 663-664 in gonorrhea, 293 roles of, 660-663, 923t of HIV infection, 301 Lay witness, 765-766 of physical neglect, 174 Lead poisoning, 130 postmortem, 780-781 Leading question, 243

1109 Child Maltreatment—A Clinical Guide

of expert witness, 717 preparing child for, 420-421, 732-734 Learned treatise, 718 religious institution and, 546, 551-552 Learning Liver, 28 cycle of violence and, 651 Liver enzyme, 141 expectation of success in, 485 Liver function test, 108 Legal definition of neglect, 155-156 Liver injury, 106 Legal issues, 707-721 Liver rupture, 790, 791f child protection laws and, 1004 Liver transaminase, 108 clergy as abuser, 546 Livor mortis, 797-798 confidentiality, 713-715 Longitudinal approach to pediatric residency training, 963-967 expert testimony, 715-719, 761-772. See also Expert Loss testimony of consciousness, 138t factual issue vs., 766 of control, 924 family abduction, 609, 611-616 as psychological issue, 438-439 forensically defensible questioning, 710-712 Loyalty, 542 hearsay, 707-710 Lung injury, 104, 109 mandated reporting, 467-468 Luring victim, via Internet, 514-516 in Munchausen syndrome by proxy, 406 prosecution of, 523-524 as obstacle to partnership, 1018 Luxation of tooth, 92 prosecution of case in faith community, 550 Lymphogranuloma venerum, 299 reporting, 707. See also Reporting Lysergic acid diethylamide, 125t in sexual abuse, 219-221 Lytic bone lesion, 29 interview and, 228 spiritual healing, 551-552 subpoena, 719-720 for therapist, 420-421 M Macrosystem, 162, 345 working with child protective services, 419 Magnesium sulfate poisoning, 128t Legal versus medical proof, 765 Magnetic resonance imaging Legalese, 351-352 of abdominal trauma, 30 Legislative mandate, 1007-1009 for neuroimaging, 27 Adoption and Safe Families Act, 1008 overview of, 15-16 Adoption Assistance and Child Welfare Act, 1007 in shaken baby syndrome, 45, 48 Child Abuse Prevention and Treatment Act, 1007 Family Preservation and Family Support Program, 1008 of subarachnoid hemorrhage, 24-25 Indian Child Welfare Act, 1007-1008 of subdural hemorrhage, 24 Multiethnic Placement Act, 1008 Magnification in sexual abuse examination, 215 Lens, 84 Mail, pornography sent through, 513-514 Lethal injury. See Death Major depressive episode, 371t Liability, immunity from, 468 Male Lie versus truth, 711 genitalia of, 271-272 Life skills, teaching of, 486 growth chart for, 200 Light sensitization, 77 as sexual abuse offender, 210-211 Linear fracture of skull, 40 Malnutrition Lingual frenula, 93-94 death from, 794-795 Lip injury, 94 in failure to thrive, 200 Liquid burn, 72-74 Maltreatment postmortem examination of, 794 causes of, 3-4 Literature child protective services in, 4-5, 919, 1009 on abusive head trauma, differential diagnosis, 517 collaborative investigation of, 5. See also on bibliotherapy, 492t-493t Multidisciplinary teams on chemical abuse, 125t-130t cultural aspects of, 557-558. See also Cultural issues on disabled child, 577t, 578t death caused by, 773-774 on Munchausen syndrome by proxy, 397t-398t definition of, 3, 995-999 on physician training, 937-944 development and, 349-359. See also Development Litigation false allegation of, 425-428 expert testimony and, 765-771. See also Expert foster care and, 600 testimony increase in research on, 7

1110 Index

information from children about, 5-6 physical abuse causing death and, 773-774 interagency partnerships on, 1013 postmortem changes and, 797-798 intimate partner violence, 644-646 sexual abuse and, 796 mandated reporting of, 4. See also Reporting sudden infant death syndrome and, 796 medical definition of, 64t transplantation and, 798-799 overview of, 1-11 Medical findings, lack of, 678, 725-726 changes in responding to, 3-8 Medical history. See History definitions of, 1-2 Medical home, 601 epidemiology of, 2-3 Medical neglect, 154t, 170-172 physical, definition of, 1-2 of children with disabilities, 577 prevention of, increased attention to, 6-7 Medical professional psychopathology related to, 367-368 hearsay exception and, 707-710 social worker and, 1031-1032 questioning by, 710-712 terminology in, 3 Medical provider in treatment of sexual abuse, 213-216 understanding consequences of, 8 Medical record Managed care, 1009-1010 of injury, 64 Management as legal document, 761-762 curriculum related to, 953t-954t in medicolegal evaluation of death, 777-778 resource, 488 of sexual abuse, 219, 247, 279-281 Mandates of discipline, 918-920 Medical science, 724 Mandated reporting. See Reporting Medical versus legal proof, 765 Manner of death, 776 Medical witness Marijuana poisoning, 125t expert, 738-739, 761-771 Marker irresponsible, 770-771 genetic, 854, 864-865 in physical abuse case, for defense, 748-751 serological, 861-862 in physical abuse case for prosecution, 736, 740 Medicolegal evaluation of death, 776-781 Marriage, 543-544 Medicolegal issues in organ transplantation, 798-799 Mass effect, 787 Membrane Mass spectrometry, 149t Descemet’s, 84 Materials, drawing, 451 hymenal Maternal deprivation syndrome, 195 anatomy of, 261-268 Maternal factors in neglect, 167-168 postmortem examination of, 791 Maxillofacial injury, 26-27 Memorandum for the Heads of Executive Departments and Mechanical asphyxia, 792 Agencies, 616t Mechanism Memory, 350-351 of death, 775 autobiographical, 347-348 of injury, 741-742 false allegation of abuse and, 425-428 Media, electronic, access to, 505-510 Mediator, inflammatory, 782 maltreatment affecting, 430-431 Medicaid for foster child, 599-600, 602-603 prosecution of maltreatment and, 351 Medical certainty, 220-221, 765 in middle childhood, 348 Medical condition mimicking abuse, 66t, 278-279 Menarche, 348 Medical diagnosis as hearsay exception, 708-709 Menkes’ kinky hair disease, 33 Medical evidence, 678, 726-727 Mental dialogue, negative, 434-435 Medical examination in investigation, 670 Mental health Medical examiner, 773-804 of foster child, 599-600, 603 burn injury and, 793-794 psychological maltreatment and, 315-341. See also cause of death and, 785-798. See also Death, cause of Psychological maltreatment data interpretation by, 781-785 Mental health expert, 766 factors affecting investigation by, 774 Mental health provider folk medicine and, 797 cooperation with other agencies by, 926 intervention-related injury and, 797 goals and mandate of, 920 manner of death determined by, 776 roles and responsibilities of, 924t mechanism of death determined by, 775 in treatment of sexual abuse, 213 medicolegal evaluation by, 776-781 Mental state of perpetrator, proving of, 745-746 metabolic disorder and, 796-797 Meperidine poisoning, 126t Mongolian spot and, 796 Mesenteric contusion, 790, 792f

1111 Child Maltreatment—A Clinical Guide

Mesosystem, 162, 345 Motor vehicle accident, 49-50 Metabolic acidosis, 142-143 Mottling, livor mortis causing, 797-798 Metabolic disorder Moxibustion, 566 abuse-related head injury vs., 52 MUDPILES, 143 postmortem examination of, 796 Multicomponent intervention, 1046-1049 postmortem screening for, 781 Multidisciplinary team Metaphyseal-epiphyseal fracture barriers to collaboration by, 918-925 characteristics of, 16-17 approach to decision making as, 920 femoral, 19 attitudes as, 925 tibial, 19 conflicting mandates and goals as, 918-920 Methadone poisoning, 126t lack of familiarity as, 921 Methamphetamine, 133-134 limitation of resources as, 920-921 Methanol poisoning, 128t loss of control as, 924 Methaqualone poisoning, 125t overcoming of, 925-931 Methotrexate, 32 physical distance as, 924-925 Metronidazole, 294t, 298 case study of, 917 MHA-TP test for syphilis, 297 disciplines, mission of, 921 MHS-5, 854 law enforcement and, 664-667 Micro-hemagglutination test, 297 in Munchausen syndrome by proxy, 403-405 Microsystem, 162, 345 need for, 917-918 Middle childhood, 348 preliminary investigative checklist for, 698-701 Milestone, developmental, 345-349. See also Development prosecution and, 724 Mineral oil, 129t in prosecution of sexual abuse, 728-730 Miosis, 138t roles and responsibilities of, 922t-924t Misinterpretation of sacred texts, 544-545 use of technology by, 931-932 Missing child legislation, 615t-616t Multiethnic Placement Act, 1008 Missing Children Act, 615t Multigenerational transmission of psychological Missing Children’s Assistance Act, 615t maltreatment, 324 Missocialization, 317, 320t Multiple choice question, 243t, 245 Mnemonic, MUDPILES, 143 Multiple-problem family, 1016 Model Multislice helical computed tomography, 15 child welfare outcomes for, 1010, 1011f Multilocus probe, 862 Educating Physicians in Their Communities, 972 Munchausen syndrome by proxy, 395-408 frustration, 575 case study of, 395 of neglect, 162-163 characteristics of, 396-397, 399 for physician training, 941t-942t in chemical abuse, 118-121 for sexual abuse interview, 238-239 conditions created in, 401-402 Modeling curriculum related to, 958t-959t cycle of violence and, 651 disability from, 578t, 582 psychological maltreatment related to, 326 failure to thrive and, 197-198 Mollera caida, 566, 582 management of, 403-406 Molluscipoxvirus, 310t overview of, 395-399 Molluscum contagiosum, 310t, 310f perpetrators of, 400-401 Mongolian spot, 66, 68f, 779, 780f postmortem examination of, 796 postmortem examination of, 796 published reports of, 397t-398t Monitoring by therapist, 433 victims of, 399-400 Mortality. See Death warning signs of, 402-403 Motile sperm Murder detection of, 853 death of abused child as, 752-754 in seminal fluid, 855t, 857 violent pornography and, 415 Motion Muriatic acid poisoning, 128 to quash subpoena, 719 Muscle enzyme, 141 to suppress, in pornography prosecution, 521 Musculoskeletal system, 16-23. See also Imaging Motor function Mycoplasma, genital, 297-298 age-related changes in, 346t Mycoplasma hominis, 297-298 maltreatment affecting, 349 Mydriasis, 84

1112 Index

drug ingestion causing, 138t on research Myelination, 787 agenda for, 986t-989t Myopathy, 141 criticism of, 981-986 of neglect, 993 opportunities for, 991t-992t N National Research Council, 980t-981t Naphtha poisoning, 128t Natural cause of death, 776 Narrative approach in interview, 240 Near-drowning, 580 National Association of Pediatric Nurse Practitioners, 949 Negative mental dialogue,434-435 National Association of Social Workers, 1033-1034 Neglect, 153-194 National Call To Action, 1073-1074 abandonment and, 174-176 National Center for Child Abuse and Neglect, 573 conceptual model of, 162-163 National Center for Missing & Exploited Children, 609, cultural aspects of, 557-558 615, 617 curriculum related to, 958t Internet and, 519, 526 definitions of, 1, 153-162 National Center for the Prosecution of Child Abuse/APRI, 932 disability resulting from, 583 National Center on Child Abuse and Neglect, 165, 579 of disabled child, 573-574, 577-578 mortality and morbidity data of, 579 dynamics of, 165-168 reporting by school and, 469 child factors in, 168 National Child Abuse and Neglect Data System, 560 parental factors in, 167-168 National Child Search Assistance Act, 616t social factors in, 166-167 National Child Victim Identification System, 519 educational, 176 National Children’s Alliance, 930-932 evaluation of, 168-170 National Clearinghouse on Child Abuse and Neglect, 932, failure to thrive and, 173, 202 foster care and, 600 1050 incidence of, 163-165 National Commission on the Future of DNA, 876 indicators of, 482 National Committee for the Prevention of Child Abuse, 579 interventions for, 176-180 National curriculum for pediatric residents, 952-960. See also intimate partner violence and, 645-646 Curriculum lethal, 794-795 National Household Survey on Drug Abuse, 325 medical, 170-172 National Incidence Studies, 2-3, 560 outcome of, 180 of neglect, 164 physical, 173-174 on early childhood and abuse, 1067 poisoning and, 132-135 on race and abuse, 561 psychological response to, 411-412 National Institute of Child Health and Human Negligence, criminal, 745 Development, 991t, 998-1000 Neisseria gonorrhoeae National Institute of Deafness and Communication conjunctivitis in, 84 Disorders, 990t gonorrhea caused by, 292-293 National Institute of Justice, 876 prophylaxis for, 294t National Institute of Mental Health Neonate on defining child abuse and neglect, 998 death of, 773, 820t research opportunities with, 992t differential diagnosis of abuse in, 31 National Institute of Nursing Research, 992t skeletal injury in, 17-18 National Institute on Alcohol Abuse and Alcoholism, 991t Neovascularization, 276 National Institute on Drug Abuse, 991t NetSmartz Workshop, 526 National Institutes of Health, 7 Network, social, 563 National Institutes of Health Child Abuse and Neglect Neurobiological disorder, 379-380 Working Group, 979-1002 Neuroimaging, 27 current goals and activities of, 999-1000 Neurological disorder from near drowning, 580 directions for future, 1000 New York Medical Society, 1006 focus areas of Newborn career development as, 993-995 death of, 773 definitions of child maltreatment as, 995-999 differential diagnosis of abuse in, 31 research as, 991-992t skeletal injury in, 17-18 objectives of, 989-990 Nicotine poisoning, 129t overview of, 979-981 Nonabusive partner, 746

1113 Child Maltreatment—A Clinical Guide

Nonincestuous child molester, 211 Oral cavity, smothering and, 792 Nonmedical treatment, spiritual, 551-552 Oral hypoglycemic agent, 139-140 Nonmotile sperm Oral injury, 91-102 detection of, 853 bite marks and, 95-96 in seminal fluid, 855t dentist and, 99-101 Nonorganic failure to thrive, 195 emotional abuse and, 95 Nonpenetrating contact, genital-to-anal, 275 impressions in, 95, 97-98 Nonrelative foster care, 595-596. See also Foster care to infant, 95 Non–rotation-based longitudinal pediatric training neglect-related, 98-99 program, 963-967 photography of, 97-98 Nonsecretor, 861 soft tissue, 93-95 Nontraumatic memory, 426-427 to teeth, 91-93 Nonverbal approaches to therapy, 422 Oral sex, 94-95 Nonverbal communication, 671-672 Organ Norm, societal, 574-576 postmortem examination of, 779-780 North American Man/Boy Love Association, 510 transplantation of, 798-799 Nuclear medicine, 14-15 Organic failure to thrive, 195 Nurse Orifice, hymenal, 260, 261, 263f-264f, 266 emergency department, 949 Oronasal blood, 792 in evaluation of child, 936-937 Orphanage, 1004-1005 Osmolar gap, 142 training of, 949-952 Osteogenesis imperfecta, 31 Nurse practitioner, 922t Osteogenic granulation tissue, 18 Nurturing Outcome lack of, 578t, 583 in child welfare system, 1009-1013 teacher as, 484 child and family service review and, 1012-1013 Nutrition in failure to thrive, 196, 198-199 conformity of states in, 1014t Nutritional intervention, 201-202 indicators of, 1014t Nystagmus, drug-related, 138t managed care and, 1009-1010 model development and, 1010 Philadelphia project, 1010-1012 O systemic factors and, 1015t Observational learning, 651 of neglect, 180 Odor, drug ingestion causing, 139t Overlying, 792-793 Offender Ownership DNA database of, 865-867 of drawing, 461-462 Internet used by, 512-518 in interagency collaboration, 928-929 to collect pornography, 512-513 for contact of potential victims, 517-518 to produce pornography, 513-514 P Office of Juvenile Justice and Delinquency Prevention, 520, p30, 854, 855t 930, 931, 990 Pain Officer, police, 660-663 congenital insensitivity to, 32 Open-ended question, 243t, 244t with first intercourse, 267 Opening statement in court, 751 Palate injury, 94-95 Operation Predator, 519-520 Pancreas Ophthalmic manifestations, 83-89 imaging of, 28-29 conjunctival, 84 injury to, 790 of cornea, anterior chamber, lens, 84 PANDA, 99-101 of eyelid and periorbital area, 83, 84t Paper for packaging evidence, 873 overview of, 83 Paracetamol poisoning, 128t retinal, 85-87 Paradox, prosecutor’s, 743 Ophthalmologic manifestations Paralysis, vocal cord, 580 in shaken baby syndrome, 84t, 85-86 Parasitic infection, 66t Opinion testimony, 716 Parent Oppositional defiant disorder, 373t of abducted child, 617-618

1114 Index

abduction by, 609-624. See also Abduction, family on prevention, 954t, 955t admission of guilt by, 423 on referral, 956t-957t failure to thrive and, 196-197 on signs and symptoms, 956t Internet use by child and, 511-512 summary of, 957t-959t neglect by, 167-168 training of, 937-946 psychological maltreatment related to, 322-323 day-long approach to, 968-972 schools working with, 476-477 for emergency medicine residents, 947-948 therapist working with, 439-440 for family medicine residents, 948 Parental abduction. See Abduction, family issues regarding abuse and, 945-946 Parental alienation syndrome, 216 literature about, 937-944 Parental intimate partner violence, cycle of violence and, 646-652 non–rotation-based longitudinal approach to, 963-967 Parental Kidnapping Prevention Act, 615t for pediatric emergency medicine fellows, 946-947 Parent-Child Conflict Tactics Scale, 560-561 on prepubertal genital examination, 944-945 Parent-child interaction progressive responsibilities model of, 941t-942t abnormality of, 3-4 for psychiatric residents, 948-949 in failure to thrive, 196, 199 Pediatric study of intimate partner violence, 626, 628 Parent-child violence, 644-645 Pediatrician Parent-focused intervention, 1045-1046 in prevention, 1063-1064 Parenting skills, 326 testimony of, 763, 766 Parent’s Guide to Internet Safety, 525 in treatment of sexual abuse, 213-216 Paroxetine, 382-383 Pediculosis pubis, 310t Partnership Pedophile, Internet use by, 505-538 interagency Pelvic fracture, 21-22 on child maltreatment, 1013 Penalty for not reporting abuse, 468 on foster care, 1013-1016 Penetration on multiple-problem families, 1016 digital, 272-273 obstacles to, 1017-1019 vaginal, 272-273 on service delivery system, 1016-1017 Penis, anatomy of, 271-272 to stop Internet crime, 519 Pepper Paternal factors in neglect, 167-168 death caused by, 793 Patient history poisoning with, 129t in failure to thrive, 198-199 Perforation in medicolegal evaluation of death, 777-778 intestinal of sexual abuse, 280-281 causes of, 107 in sexual abuse examination, 253-255 of thoracoabdominal injury, 106-107 of duodenum, 29-30 Pattern of injury evaluation of, 109 extragenital, 275 intestinal, 105-106 of genital fondling, 272-273 rectal, 30 healing or healed, 276-277 Perianal infection, herpes, 304 of labial agglutination, 274 Perineum, 260 oral, 95 Periorbital area, 84t in postmortem examination, 782-783, 783-785 Periosteal reaction, 31-32 thoracoabdominal, 103-104 Peritoneal lavage, 108 from vaginal penetration, 273, 284 Peritonitis, 103, 106 from vulvar coitus, 273 Perpetrator Pediatric condition falsification, 396 child’s identification of, 709 in chemical abuse, 118 DNA database of, 865-867 Pediatric emergency medicine fellow, 946-947 examination of, 905-909 Pediatric resident factors in determining, 757-759 curriculum for, 943t, 952-960 of family abduction, 610-611 for child abuse and forensic pediatrics fellowship, forensic examination of, 877 960t-963t of head injury, 49 on evaluation and management, 952-953 interview of, 734-735 goal of, 952t of intimate partner violence, 641-642 on normal vs. abnormal, 955t-956t law enforcement interview of, 674-675 on pediatrician’s role, 953t of Munchausen syndrome by proxy, 400-401

1115 Child Maltreatment—A Clinical Guide

of sexual abuse, profile of, 210-211 in failure to thrive, 199, 200t Perphenazine poisoning, 126t of foster child, 596-597 Person Picking an Apple from a Tree task, 450 gross external, 779 Personal body integrity, 436-437 interview questions during, 244-246 Personal insight, 491 in law enforcement investigation, 670t Personal Responsibility and Work Opportunity in medicolegal evaluation of death, 778 Reconciliation Act, 1018 pretrial, 761-762 Personality disorder, 378 role of physician in, 936-937 Personalizing of victim, 752-753 in sexual abuse, 214, 253-288 Personnel accidental injury and, 274-275 religious, 547-548 diagnostic findings in, 281-284 school, 473-475 documentation of, 279-281 Persuasion in courtroom, 751-754 forensic evidence in, 278 Pew Internet and American Life Project, 524 genital and anal anatomy in, 260-272. See also Pew Internet tracking report, 511 Anatomy Phencyclidine poisoning, 125t healed and healing injury and, 276-277 Phenformin poisoning, 127t indications for, 256-257 Phenolphthalein poisoning, 128t medical conditions mimicking abuse and, 278-279 Phenothiazine poisoning, 126t positioning for, 258-260 Phenytoin poisoning, 127t preliminary evaluation in, 253-255 Philadelphia Outcome Measures Project, for 1010-1012 preparing child for, 257-258 Photodermatitis, 77 purpose of, 253 Photographic exploitation, 678 sexually transmitted disease and, 278 Photography sodomy and, 275 forensic value of, 65 trauma patterns in, 272-274 of oral injury, 97-98 of sexual assault suspect, 905-909 postmortem, 783 of thoracoabdominal injury, 107-108 Phthirus pubis, 310t Physical neglect, 154t, 173-174 Physical abuse psychiatric disorder related to, 369-374 bruise in, 63-72 Physical strength, child’s sense of, 436 in cycle of violence, 647 Physician. See also Pediatric resident death caused by, 773-774 evaluation by, 935-936 definition of, 1-2, 1032 roles and responsibilities of, 922t, 936-937 of disabled child, 574, 577t, 578t training for. See Training imaging of, 13-36. See also Imaging in treatment of sexual abuse, 213-216 indicator of, 481t-482t Physician-patient privilege, subpoena and, 764 intimate partner and, 640 Phytophotodermatitis, 77 oral injury from, 95-96 Pine oil poisoning, 128t poisoning with, 124 Ping-pong deformity of skull, 40 prosecution of Placement timetable, 1018 alternative theories of causation and, 743-744 Plain film, 14t confronting defendant in, 746-751 Planning in interagency collaboration, 929t determining likely perpetrator, 757-759 Plasticity of development, 344 expert testimony in, 736-740 Play mechanism of injury and, 741-742 lack of opportunities for, 411 nature of injuries in, 740-741 by preschooler, 348 persuasion in, 751-754 by toddler, 347 proving identity of perpetrator, 744-746 Play therapy, 424-425 timing of injury and, 742-743 Pleural effusion, 22 psychologic response to, 410-413 Pluralism, cultural, 568 psychopathology related to, 368-369 Pneumothorax, 104 skin manifestations of, 63-64 evaluation of, 109 Physical development, 346t imaging of, 22 Physical examination Podofilox, 306t court-ordered, 715 Poison ivy, 66t, 67, 69f curriculum related to, 964t-965t Poison Prevention Packaging Act, 130

1116 Index

Poisoning. See also Intentional ingestion Present sense impression, 727 death from, 793 Preservation of crime scene, 669t definition of, 114 Pretrial preparation, 761-764 physical abuse with, 124 Prevalence of abuse, 560 postmortem examination for, 780 Prevent Abuse and Neglect through Dental Awareness, 99-101 Police. See Law enforcement Prevention, 1063-1090 Police Foundation, 663 advocacy and, 1073-1074 Policy assessment in, 1070-1071 on corporal punishment, 472-473 challenges of, 1074-1075 disability and, 584-585 curriculum related to, 954t, 955t on family abduction, 611-616 defining child abuse and neglect and, 1065 for prevention of psychological maltreatment, 333-334 of family abduction, 618-619, 621 of religious institution, 540, 546, 548, 550 family and community context of, 1067-1068 school, for reporting abuse, 468-471 importance of, 1063-1064 Polymerase chain reaction, 864-865 increased attention to, 6-7 Pornography of Internet crime, 524-527 collector of, 512-513, 520-522 as law enforcement role, 661 producer of, 513-514, 522-523 management in, 1071-1073 psychological effect of, 415 National Research Council’s report on, 980t-981t Positioning for examination of sexual abuse, 258-260 of neglect, 178-180 Positron emission tomography, 430-431 pediatrician’s role in, 1064-1065 Postal Service, 513-514, 519 psychiatry and, 383-384 Postexposure antiretroviral prophylaxis, 302-303 of psychological maltreatment, 331-334 Postmortem examination, 780-781 religious institutions involved in, 552-553 in medicolegal evaluation of death, 778 risk for abuse and, 1066-1069 Postrecovery response after abduction, 619t safe environment questionnaire and, 1083-1084 Post-traumatic stress disorder in school, 475-478 developmental stage and, 417 screening in, 1069-1070, 1084-1090 drawing and, 460 of shaken baby syndrome, 54, 56 physical abuse related to, 373 societal context of, 1068-1069 sexual abuse and, 217-218, 377, 416 supervision of school personnel and, 473-475 Poverty types of, 1065-1066 child health outcomes related to, 562-563 Primary care provider, 213-216 disability and, 584 Primary syphilis, 296 failure to thrive and, 196 Privilege, physician-patient, 764 Power Privileged communication, 713-715 child’s sense of, 436 Probable cause, for search warrant, 677-678 clergy’s misuse of, 544-545, 548-549 Probe, multilocal, 862 intimate partner violence and, 643 Proctitis, 310t Precursor protein, beta-amyloid, 787 Proctocolitis, 310t Pregnancy Producer of pornography, 513-514, 522-523 cocaine use during, 135 Professional training. See Training intimate partner violence during, 581-582 Profile methamphetamine use during, 133 of abducting parent, 620t-621t substance abuse in, 581 of chat room participant, 514, 516 Preliminary investigative checklist, 698-701 of sexual abuse perpetrator, 210-211 Preliminary rape case information form, 912-913 Progressive responsibilities model, 941t-942t Premature infant, abandonment of, 175 Promethazine poisoning, 126t Prepubertal child, vagina of, 290t Proof Prepubescent sexual assault information form, 898-900 beyond reasonable doubt, 724-725 Preschool-age child of injury, expert testimony of, 736-740 aggression in, 368-369 medical vs. legal, 765 developmental milestones of, 345, 346t, 347-348 required to report abuse, 468 drawings by, 453t Prophylaxis evidence collection from, 872 postexposure antiretroviral, 302-303 psychotherapeutic intervention for, 381 for sexually transmitted disease, 290-291

1117 Child Maltreatment—A Clinical Guide

Propoxyphene poisoning, 126t parental shame and violence as, 322-323 Propranolol, 382 socioeconomic stress and, 326-327 Prosecution substance abuse as, 325 challenges of, 723-725 consequences of, 327-331 developmental issues in, 350 age- and gender-related, 330-331 DNA evidence for, 875-877 externalization as, 329-330 in faith community, 550 insecure attachment style as, 327-328 immunity from, for reporting abuse, 468 internalization as, 329 of Internet pornography, 520-523 social and cognitive impairment as, 328-329 of physical abuse or homicide, 736-754. See also Physical cultural issues in, 318, 321 abuse, prosecution of definition of, 2, 316-318 of religious institution, 551 of disabled child, 573 of sexual abuse, 725-736. See also Sexual abuse, incidence study of, 321 prosecution of oral manifestations of, 95 Prosecutor psychological response to, 413 goals and mandate of, 919 psychopathology related to, 373-374 interagency coordination and, 927 public policy concerning, 333-334 roles and responsibilities of, 923t treatment of, 331-333 Prosecutorial Remedies and Other Tools to End the Psychological response to maltreatment, 410-418 Exploitation of Children Today Act, 616t assessment of, 428-432, 434 Prosecutor’s paradox, 743 drawing in, 449-465. See also Drawing Prostatic glycoprotein p30, 854 general measures for, 428-429 Protection of victim psychophysiological, 430-431 from Internet crime, 524 specialized tools for, 429-430 in Munchausen syndrome by proxy, 405-406 to emotional abuse, 413 Protective custody, 597 to intimate partner violence, 628-629 Protein to physical abuse, 410-413 beta-amyloid precursor, 787 to sexual abuse, 413-416 MHS-5, 854 variations in, 417-418 prostatic glycoprotein p30, 854 Psychological treatment, 418-440 Protocol assessment for, 428-432 interview, 730-731 general measures for, 428-429 for investigation, 670t psychophysiological, 430-431 for multidisciplinary investigation, 666 specialized tools for, 429-430 Protozoan infection, 298 Pseudocyst, pancreatic, 28 planning phase of, 422-428 Psychiatric resident, training of, 948-949 false accusations and, 425-428 Psychiatrist, 384-385 family/group approaches to, 422-424 roles and responsibilities of, 924t individual approach to, 422 Psychobiologic correlates of maltreatment, 379-380 nonverbal approaches to, 422 Psychological assessment, 428-432 play therapy approaches to, 424-425 general measures for, 428-429 stabilization and neutralization phase of, 432-440 overview of, 409 body integrity in, 436-437 psychophysiological, 430-431 damage assessment in, 434 specialized tools for, 429-430 dispelling fear in, 433 Psychological factors family issues in, 439-440 in Munchausen syndrome by proxy, 396, 401 loss and betrayal and, 438-439 neglect related to, 168 self-esteem and, 434-436 Psychological fear, 433-434 support system for, 432 Psychological maltreatment, 315-341 validation of child in, 432-433 age-specific examples of, 319t-320t verbal expression in, 437-438 assessment of, 331 validation phase of, 418-421 causes and correlates of documentation in, 419-420 child- and parent-related factors, 321-322 identification of abuse in, 418-419 family dynamics in, 323-324 legal issues in, 420-421 lack of parenting skills as, 326 Psychologist mental illness as, 324-325 goals and mandate of, 918-920

1118 Index

roles and responsibilities of, 924t by law enforcement, 671-673 Psychopathology, 367-393. See also Psychological response for school personnel, 474-475 to maltreatment with sexually abuse child, 242-246 abuse-related, 367-368 for intimate partner violence screening, 631t in chemical abuse, 118-121 sensitive, 1069-1070 diagnostic criteria for Questioning, forensically defensible, 710-711 for attention deficit/hyperactivity disorder, 369t- Questionnaire of Experiences in Dissociation (QED), 429 370t for conduct disorder, 375t-376t for generalized anxiety disorder, 372t R for major depressive episode, 371t Raccoon eye, 27 for oppositional defiant disorder, 373t Race for substance abuse, 378, 379t culture and, 560-563 emotional maltreatment causing, 374 foster care and, 561t interventions for, 380-384 RADAR card, 637 physical abuse causing, 368-374 Radiograph, diagnostic, 14 physical maltreatment causing, 368-374 Radiographic evaluation, postmortem, 780 prevention of maltreatment and, 383-384 Radiology, 13-36. See also Imaging psychobiologic correlates and, 379-380 Radius, diaphyseal fracture of, 20 as result of abuse, 367-368 Rape case information form, 912-913 role of psychiatrist in, 384-385 Rape kit in prosecution of sexual abuse, 728 sexual abuse causing, 374-379 Rape trauma syndrome, 421 Psychophysiological assessment, 430-431 Rapport Psychosis, drug-related, 138t drawing and, 456-457 Psychosocial development, 482. See also Development with sexually abused child, 239-241 Psychosocial disorder, 372-373 Realism in drawing, 454t Psychosocial dwarfism, 197-198 Reasonable certainty, 716 Psychosocial intervention in failure to thrive, 202 Reasonable doubt, proof beyond, 724-725 Psychotherapeutic intervention, 380-383 Reasonable medical certainty, 765 Psychotherapy in Munchausen syndrome by proxy, 406 Rebleeding, 53 Puberty, 348-349 Recall, maltreatment affecting, 350 Public policy Recklessness, 745 disability and, 584-585 Record for prevention of psychological maltreatment, 333-334 of bite injury, 96 Public welfare as obstacle to partnership, 1018 confidential, 713 Pudenda, 260 of foster child, 603-604 Pulmonary contusion, 22, 104f, 105f in identification of abuse, 419-420 evaluation of, 109 of injury, 64-65 Puncture wound, 63 medical examiner’s investigation and, 774-775 Punishment in medicolegal evaluation of death, 777 corporal of sexual abuse, 279-281 religion advocating, 546-547 testimony about, 714-715 in school, 471-473, 564-565 Record check, background, 474 disclosure leading to, 710 Rectal perforation, 30 Pupil, dilation of, 84 Reference for school personnel, 475 Puppetry, 487 Referral Purtscher’s retinopathy, 44, 84t, 87 for bite injury, 96 for child abuse investigation, 669t curriculum related to, 956t-957t Q in failure to thrive, 201 Qualifications of expert witness, 715 prevention and, 1072 Quashing of subpoena, 719-720 Regional skeletal injury, 19-23 Question Rejection, 328 hearsay exception and, 707-710 as form of psychological maltreatment, 317, 319t hypothetical, 716 Relationship interview foster care and, 600

1119 Child Maltreatment—A Clinical Guide

in intimate partner violence, 643-644 emergency medicine, 947-948 maltreatment affecting, 358-359 family medicine, 948 psychological maltreatment related to, 323 psychiatric, 948-949 Religion Residual or child hearsay exception, 709-710 denial of care and, 795 Residual signs of injury, 276-277 medical neglect and, 171-172 Resiliency, 491, 493 Religious exemption to state statute, 189-193 Resource Religious freedom, 568 as barrier to interdisciplinary collaboration, 920-921 Religious institution, 539-555 for DNA testing access to vulnerable children in, 543 crisis of, 867-869 denial in, 542 lack of, 878-879 discomfort with sexuality in, 543-544 on intimate partner violence, 632 misuse of sacred texts by, 544-545 medical examiner’s investigation and, 774 need for safeguards in, 545-548 prevention and, 1072-1073 overview of, 539-541 of religious institution, 550 positive trends concerning, 550-552 for social worker, 1050 prosecution of abuse cases in, 550 Resource management, 488 reporting laws affecting, 549 in DNA testing, 880 research needed about, 552-553 Restriction fragment length polymorphism, 862-864 secrecy in, 543 lack of resources for, 878-879 self-care of clergy and, 548-549 Resuscitation, cardiopulmonary trust in, 542 injury related to, 789, 797 vulnerability of victim in, 541-542 retinal hemorrhage in, 85 Renal injury, 29, 790 Retaliation defense, 735 Repetition in drawings, 452, 455 Retina, blunt trauma to, 85 Reporting Retinal hemorrhage of abuse by clergy, 539-540, 549 differential diagnosis of, 85 American Academy of Pediatrics criteria for, 64t in shaken baby syndrome, 43-44, 85-86, 787-790 of bite injury, 96 Retinopathy, Purtscher’s, 44, 87 by child, 5-6 Retraction, of disclosure of sexual abuse, 211, 233 confidentiality and, 715 Retraction ball, axonal, 47 content for, 467-468 Reunion of abducted child with parent, 620t cultural practices and, 566-567 Reversal sign in shaken baby syndrome, 47-48 curriculum related to, 959t Review of systems income related to, 561t of law enforcement investigation, 681 in failure to thrive, 198 as major change, 4 of sexually abused child, 231 of Munchausen syndrome by proxy, 397, 404 Review program, child fatality, 702-703 by religious institution, 549 Revolution, DNA, 862-863 by school, 467-471 Rib fracture, 104, 105f, 108-109 of sexual abuse, 219-221 differential diagnosis of, 31 statutory rape and, 875 imaging of, 22 teachers mandated to, 467 postmortem examination of, 790, 791f by therapist, 419 in shaken baby syndrome, 44-45 Research Rickets, 17, 31, 32 agenda related to, 986t-989t Right to self-protection, 436-437 career development in, 993-995 Ringworm, 66, 68f criticism by, 981-984 Risk factor on cycle of violence, 650-651 for disabled child, 574-576 on drawings, 449-450, 462 for failure to thrive, 196-197 increase in, 7 for HIV infection, 301t, 302t memory, 425-431 Internet as, 505-538. See also Internet on religious institutions, 552-553 for intimate partner violence, 641-645 screening and, 1069 parent-child dyad and, 1066-1067 suggestions for, 984t-986t for psychological maltreatment, 326-327 Resident for sexual abuse, 210-211 curriculum for, 952-960 Risk-taking behavior, 369

1120 Index

Rohypnol Scalp injury, 38, 71 to facilitate sexual abuse, 121-122 postmortem examination of, 786, 787f poisoning with, 125t Scan, nuclear medicine, 14-15 Role Scapegoat, 323-324, 326-327 of law enforcement, 660-663 Scapular fracture, 21 physician’s Scarring, 276-277 curriculum related to, 952-960, 972 Scene, crime. See Crime scene in prevention, 1064-1065 School, 467-503 Role model, 488-489 abuse by employee of, 470-471, 473 Roman Catholic Church, settlements against, 539 child welfare and, 1020-1021 Root fracture of tooth, 93 consequences of maltreatment and, 359 Rotational head injury, 40-49 corporal punishment in, 564-565 associated injury with, 44-45 discipline in, 471-473 imaging in, 45 indicators of abuse and, 478-483 intracranial injury in, 45-48 personnel hired by, 473-475 mechanism of injury in, 40-42 psychological maltreatment and, 333 presentation of, 42 reporting by, 467-471 retinal hemorrhage in, 43-44 immunity from prosecution for, 468 timing of, 48-49 level of proof required for, 468 Runaway, 479t, 481t, 483 penalty for failing to, 468 Rupture of liver, 790, 791f policy on, 468-471 supporting child after, 471 resiliency of child and, 491, 493 S teachers and Sacred text, misuse of, 544-545 characteristics of, 483-484 Sadness, 438-439 strategies for, 484-491 Safe environment, 1075-1076 training of staff of, 493 Safe haven law, 175-176 School-age child Safeguard aggression in, 369 for confidential information, 713-715 drawings by, 453t-454t in religious institution, 545-546, 550 evidence collection from, 872 Safety School counselor, 924t environmental, 132-133 SCID-D, 429-432 in failure to thrive, 202 Science, criminal justice and, 724 on Internet, 524-527 Science policy for research, 981t in religious institution, 542 Scintigraphy during therapy, 434 bone, 15 Salary issues in child welfare, 1023-1024 spinal, 21 Salicylate poisoning, 127t Screening Saliva for abuse, 729-730 collection of, 874 CAGE, 1085-1086 as evidence, 854, 861 prevention and, 1069-1070 Salt in failure to thrive, 200-201 excessive amount of, 793 for intimate partner violence, 626-627, 629-631 ingestion of, 142 for neglect, 169-170 poisoning with, 129t of religious staff, 547 Sanctuary, religious, 542 of school volunteers, 476 SANE nurse Scribble chase, 456-457 roles and responsibilities of, 922t Scribbling, 453t training of, 950-952 Scurvy, 32-33 Sarcoptes scabei, 310t Search, crime scene, 676-679 SART clothing documentation, 901-902 Search warrant, 910-911 Scabies, 310t applications for, 685-697 Scald burn, 72, 74 probable cause and, 677-678 postmortem examination of, 794 for unconscious victim, 903-904 Scale, conflict tactics, 560-561, 646 Second impact syndrome, 53

1121 Child Maltreatment—A Clinical Guide

Secondary syphilis, 296-297 indicator of, 481t-482t Second-degree burn, 77-78 interviewing child about, 227-251 Secrecy in religious institution, 543 caregiver history in, 230-232 Secret Service, 519 developmental considerations in, 235-237 Security, maltreatment affecting, 358 disclosure process in, 232-235 Seizure, drug-related, 138t documentation of, 247-249 Selective serotonin reuptake inhibitor, 382-383 emotional issues in, 237-238 Self-care by clergy, 548-549 in medical evaluation, 239-247 Self-esteem models for, 238-239 building of, 490 overview of, 227-230 emotional maltreatment and, 413 of intimate partner, 640-641 psychological mending of, 434-436 legal issues in, 219-221 Self-image, drawing of, 458 medical evaluation of, 214, 253-288 Self-inflicted wound, 66t accidental injury and, 274-275 Self-protection, right to, 436-437 diagnostic findings in, 281-284 Self-soothing, 438-439 documentation of, 279-281 Semen forensic evidence in, 278 acid phosphatase in, 854 genital and anal anatomy in, 260-272. See also Anatomy characteristics of, 853 healed and healing injury and, 276-277 collection of, 874 indications for, 256-257 as forensic evidence, 853 medical conditions mimicking abuse and, 278-279 genital-to-anal contact and, 275, 278 positioning for, 258-260 Seminal fluid preliminary evaluation in, 253-255 collection of, 856-857 preparing child for, 257-258 as forensic evidence, 853-856 purpose of, 253 testing for, 853 sexually transmitted disease and, 278 Sensitive question, 1069-1070 sodomy and, 275 Sensitivity to light, 77 trauma patterns in, 272-274 Sensitization, 379-380 perpetrator profile in, 210-211 Sentinel injury in shaken baby syndrome, 790 physical examination of, 214 Separation in Munchausen syndrome by proxy, 404-405 accidental injury and, 274-275 Serial killer, 415 diagnostic findings in, 281-284 Serology testing, 861-862 documentation of, 279-281 Sertraline, 382-383 forensic evidence in, 278 Service delivery system, 1016-1017 genital and anal anatomy in, 260-272. See also Anatomy Service provision by child protective services, 664t healed and healing injury and, 276-277 Sex Abuse Legitimacy Scale, 431 indications for, 256-257 Sexual abuse, 209-226 medical conditions mimicking abuse and, 278-279 behavioral characteristics of, 483 positioning for, 258-260 biological evidence in, 869-881 preliminary evaluation in, 253-255 acute examination in, 873-875 preparing child for, 257-258 case studies of, 869-871 purpose of, 253 cooperation of child in, 871-872 sexually transmitted disease and, 278 case histories of, 282-284 sodomy and, 275 causes of, 4 trauma patterns in, 272-274 curriculum related to, 959t postmortem examination and, 796 definition of, 2, 1032-1033 prosecution of, 725-736 of disabled child, 574 common defenses against, 735-736 disclosure process in, 211-212 disclosure by victim and, 725-726 drugs given to facilitate, 121-123 expert testimony in, 728 effects of, 217-219 interview of medical personnel in, 727-728 epidemiology of, 209-210 interview of suspect in, 734-735 expert testimony about, 765-767 medical evidence and, 726-727 false allegations of, 216-217 other abuse and, 731-732 family therapy and, 423 preparing child for court in, 732-734 forensic evidence collection in, 853-858 victim as witness in, 728-731

1122 Index

psychological response to, 413-416 Shame psychopathology related to, 374-379 psychological maltreatment related to, 322-323 religion and, 545 as response to abduction, 619t risk factors for, 210-211 Short tandem repeats, 865 role of healthcare provider in, 213-216 Shortage of social workers, 1022-1023 of medical provider, 213-216 Sign, stacked coin appearance, 30 of mental health professional, 213 Silence about clergy abuse, 540 symptoms of, 212-213 Silver Drawing Test, 450 Sexual assault information form, prepubescent, 898-900 Silverman, Frederick, 1006 Sexual assault nurse examiner, training of, 950-952 Skeletal injury Sexual assault suspect examination, 905-909 curriculum related to, 958t Sexual behavior imaging of, 16-23. See also Imaging as indication of sexual abuse, 212-213 Skeletal survey, 14, 17 maltreatment affecting, 352-354 Skills problematic, 218-219 academic, 490-491 Sexual contact, anal, 270-271 communication, 486-487 Sexual interaction stage of abuse, 516 computer, 506 Sexual risk taking, 369 confrontation, 488-489 Sexuality, religion and, 543-544 coping, 488-489 Sexually transmitted disease, 289-313 life, 486 bacterial social, 485-486 chancroid as, 299 Skills list for forensic pediatrics, 963t Chlamydia trachomatis causing, 293-295 Skin genital mycoplasmas as, 298-299 bruising and. See Bruise gonorrhea as, 292-293 infection and, 66t, 304 granuloma inguinale as, 299 as protective organ, 63-64 lymphogranuloma venereum as, 299 Skull fracture syphilis as, 296-297 imaging of, 26 trichomoniasis as, 298 postmortem examination of, 786-787 vaginosis as, 297-298 presentation of, 39-40 conjunctivitis in, 84 in shaken baby syndrome, 45-46 general principles regarding, 289-292 Slap, 71-72 miscellaneous, 309-310 Sleep, overlying and, 792-793 risk for, 278 Smothering, 792 viral Social capital, 562-563 hepatitis as, 308-309 Social context herpes simplex virus causing, 303-305 prevention of abuse and, 1068-1069 human immunodeficiency, 299-303 sexual abuse and, 352 human papilloma virus causing, 305-308 Social development Shaft, tibial, fracture of, 19 age-related changes in, 346t Shaft fracture, fibular, 19 maltreatment affecting, 351-352 Shaken baby syndrome, 40-49, 579 psychological maltreatment affecting, 328-329 associated injury with, 44-45 Social history defense medical witness and, 748-751 in failure to thrive, 199 educating of judge and jury about, 737-738 of sexually abused child, 231 eye in, 87 Social isolation, 166 imaging in, 45 Social services intracranial injury in, 45-48 child welfare and, 1019-1020 law enforcement investigation of, 680-681 curriculum related to, 962t mechanism of, 86 Social skills, 485-486 mechanism of injury in, 40-42 Social support, 326-327 postmortem examination of, 787-790 Social worker, 1031-1061 presentation of, 42 assessment by, 1041 retinal hemorrhage in, 43-44, 85-86 child maltreatment and, 1031-1032 timing of, 48-49 critical thinking skills of, 1038-1039 Shaken impact syndrome, 788 decision making by, 1034-1038

1123 Child Maltreatment—A Clinical Guide

defining child abuse and neglect by, 1032-1033 Staffing as barrier to interdisciplinary collaboration, 921 defining social work, 1033-1034 Staging, Tanner, 522 definition of, 1034 Stairway fall, 107 evidence-based practice of, 1039-1041 Staphylococcal impetigo, 77 Internet resources for, 1050 State interventions by, 1042-1049 definitions of neglect of, 155-159 child-focused, 1043-1045 religious exemptions to statutes of, 189-193 empirically supported, 1042-1043 State law on family abduction, 613-615 multicomponent, 1046-1049 Statement parent-focused, 1045-1046 admissible, 727 shortage of, 1022-1023 at deposition, 764 Societal issues, risk to disabled child and, 574-576 hearsay, 762 Society of the Prevention of Cruelty to Animals, 1005 Statute Society of the Prevention of Cruelty to Children, 1006 religious exemptions to, 189-193 Socioeconomic status, 326-327 on reporting abuse, 469-470 SODDI defense, 735 Step-wise model for sexual abuse interview, 239 Sodomy, 275 Sternal fracture, 16t, 21, 104 Soft palate injury, 94-95 Stimulation, lack of, 583 Soft tissue, 779 Stimulus, sexual, 415 Software, Internet blocking, 525 Stomach, imaging of, 29 Solicitation via Internet, 517-518 Straddle injury, 271f Solid organ injury, 106 Strangulation Solvent in manufacture of methamphetamine, 133 marks from, 73f Special investigative technique, 675-677 postmortem examination of, 792 Special needs child, 573-594. See also Disabled child Strength, child’s sense of, 436, 439 Specialized foster care, 596 Stress response, 379 Stria, 66t, 68f Specific intent, 745 Structural violence, 564-565 Specificity of radiological findings, 16t Structured Clinical Interview of DSM-IV–Dissociative Specimen. See also Evidence Disorders, 429-430, 432 collection procedure for, 776-777 Subacute injury, 742 postmortem, 780-781 Subarachnoid hemorrhage of seminal fluid, 853-856 imaging of, 24-25 Spectrometry, mass, 149t postmortem examination of, 787 Spectroscopy, ultraviolet, 148t in shaken baby syndrome, 789 Speculum, 215, 260 Subcapsular hematoma of liver, 28 Speech pattern in excited utterance, 708 Subconjunctival hemorrhage, 84, 85f Sperm as forensic evidence, 270, 679 Subdural hematoma Spermarche, 348-349 in accidental injury, 49-50 Spermatogenesis, 853 imaging of, 23-24 Spermatozoon, 853 in shaken baby syndrome, 789f Spinal injury in skull fracture, 40 abuse causing, 580 Subdural hemorrhage, 46 imaging of, 20-21 Subgaleal hemorrhage, 38f, 39 Splash burn, 72, 74, 75f Subluxation of vertebral body, 21 Spleen, 28 Subperiosteal hematoma, 17, 19 Spontaneity of statement, 708, 710 Subpoena, 719-720, 763-764 Spot, Mongolian, 796, 779, 780f in law enforcement investigation, 670 Spot toxicology test, 148t Substance abuse Spouse abuse. See Intimate partner violence criteria for, 378t Squeezing, thoracic injury from, 22 fetal exposure to, 581 Stabilization as goal of therapy, 435-436 physical abuse related to, 373 Stacked coin appearance, 30 psychological maltreatment and, 325 Staff questions about, 1077 religious, 547 as risk factor for abuse, 1064-1065 school, 473-476, 493 by sexually abused child, 416 Staff retention in child welfare, 1024 Success, expectation of, 485

1124 Index

Sucker, 66t, 72, 73f Tachycardia, 138t Sudden infant death syndrome Tachypnea, 138t law enforcement investigation of, 681 TADD, 53 as natural death, 776 Talk and deteriorate or die syndrome, 53 postmortem examination of, 796 Tanner staging, 522 Suffocation, 580 Teacher Sugar, poisoning with, 129t characteristics of, 483-484 Suicide strategies for, 484-491 physical abuse related to, 373-374 Team, interdisciplinary. See Interdisciplinary collaboration sexual abuse related to, 377, 379 Technical evidence, 678 Sulfonylurea poisoning, 128 Technique, special investigative, 675-676, 677t Sunburn, 77, 78f Technology, 931-932 Supervision Temperature abnormality, 138t of Internet usage, 511-512, 524-526 Terrorization, 317, 320t of religious personnel, 547-548 Terson syndrome, 44, 86 of school personnel, 473 Tertiary syphilis, 296 of school volunteers, 476 TESS, 115, 116t Support Testimony for child, 432 curriculum related to, 959t for child testifying in court, 734 expert, 715-719, 761-772. See also Expert testimony as law enforcement role, 661 opinion, 716 Suppression stage of sexual abuse, 516 preparing child for, 420-421, 732-734 Surgery for genital warts, 307-308 reviewing client records and, 714-715 Survival, 782-783 on sexual abuse, 220-221 Suspect. See also Perpetrator Tetrahydrocannabinol, 125t examination of, 905-909 “The Battered Child Syndrome,” 559 forensic examination of, 877 Theology, toxic, 544-545 interview of, in prosecution of sexual abuse, 734-735 Theory Suspect abuse, 65, 78-79 of causation, 743-744 Suspected Child Abuse and Neglect progam, 972 of intimate partner violence, 641 Swab of mind, 344, 352 of bite mark, 783 of neglect, 162-163 in evidence collection, 779 Therapist Sweating, drug-related, 139t goals and mandate of, 920 Symmetric growth retardation, 198 identification of abuse by, 418-419 Symptom, child’s understanding of, 434 roles and responsibilities of, 924t Symptom checklist, 428 Thin layer chromatography, 148t Syphilis, 32-33, 296-297 Third-degree burn, 77-78 System Third National Incidence Study of Child Abuse and Neglect, 1063 building of, 930f Thoracic trauma, 22 child welfare, 1003-1030. See also Child welfare system Thoracoabdominal injury, 103-112 CODIS, 865-869 detection of, 107-110 goals and mandate of, 918-920 epidemiology of, 103 medical science and criminal justice, 724 evaluation of, 106 psychological maltreatment and, 333 mechanism of, 103-106 national child abuse and neglect data, 560 Tibial fracture, 19 national child victim identification, 519 Time spent on Internet, 505f service delivery, 1016-1017 Timeline, 744-745 support, 432 Timing of injury, 742-743 toxic exposure surveillance, 115, 116t postmortem examination and, 782-783 Systems, review of in shaken baby syndrome, 48-49 in failure to thrive, 198 Toddler of sexually abused child, 231 developmental milestones of, 345-347 fracture in, 19, 31 scribbling by, 453t T Toluene poisoning, 128t Tabasco sauce, poisoning with, 129t Tongue injury, 94

1125 Child Maltreatment—A Clinical Guide

Tooth injury, 91-93 Toxic Exposure Surveillance System, 115, 116t U Ulnar fracture, 20 Toxic theology, 544-545 Ultrasound Toxicity, 793. See also Intentional ingestion; Poisoning; overview of, 16 Unintentional ingestion of thoracoabdominal injury, 110 Toxicology Ultraviolet spectroscopy, 148t in drug ingestion, 144-146 Unconscious victim, 903t-904t laboratory report of, 147 Unconsciousness, 70f postmortem, 780 Underinsurance, 584 Toxidrome, 138t, 145 Understanding Child Abuse and Neglect, 980t-981t Trace evidence, 779 Traction, vitreous, 43 Unestrogenized hymen, 262, 266 Training Uniform Child Custody and Jurisdiction Act, 615t DNA, 876 Uniform Child Custody Jurisdiction and Enforcement Act, of nurse, 949-952 616t emergency department, 949 Unintentional ingestion, 130-149 sexual assault nurse examiner, 950-952 blood urea nitrogen in, 141 as obstacle to interagency partnerships, 1017 case study of, 131-132, 141-144 of pediatric resident, 937-946. See also Pediatric resident clinical presentation of, 138t-139t for practicing physician, 972 definition of, 114 of school staff, 493 laboratory evaluation of Translational force in skull fracture, 786-787 aldolase in, 141 Transmission of violence, intergenerational, 646-652 anion gap in, 142-144 Transplantation, organ, 798-799 arterial blood gases in, 142 Trauma. See Injury creatine phosphokinase in, 141 Trauma Symptom Checklist for Children, 430 hypoglycemia in, 136-137, 139-140 Traumatic memory, 425-428 hyponatremia in, 140-141 Treatise, learned, 718 liver enzymes in, 141 Treatment metabolic acidosis in, 142-143 drawing as, 450-451, 456-460 osmolar gap in, 142 as hearsay exception, 708-709 urinalysis in, 141-142 as obstacle to partnership, 1018 as neglect, 132-133 psychological, 409-448. See also Psychological treatment numbers of, 116t Trial overview of, 130-131 civil versus criminal, 764, 765t patient history of, 137t preparation for, 763-764 toxicology in, 144-146 Triangling, 324 water intoxication and, 140-141 Trichloroacetic acid, 306t, 307 United Nations organizations, 559, 585 Trichomoniasis Universal prevention interventions, 1065 diagnosis and treatment of, 298 Unsolicited contact via Internet, 517-518 prophylaxis for, 294t Unsolved sexual assault, 877-878 Tricyclic antidepressant Ureaplasma urealyticum, 298-299 poisoning with, 126t-127t Urethra for post-traumatic stress disorder, 382 imaging of, 29 Truancy, 155t, 176, 479t, 481t, 494 postfondling dysuria and, 268, 270, 273 Trust Urinalysis, in drug ingestion, 141-142 in interagency collaboration, 929t Urine, postmortem examination of, 780 in religious institution, 542 Urine drug screen, 146t of teacher, 484 US Advisory Board on Child Abuse and Neglect, 928 Truth US Customs Service, Internet and, 519 importance of, 709 US Department of Justice Office for Victims of Crime, 551 lie vs., 711 US National Family Violence Survey, 560 TSC-C, 430 US Postal Service, 513-514, 519 Turf battle, 920 US Secret Service, 519 Turnover rates in child welfare, 1023 Utterance, excited, 708

1126 Index

treatment of, 306-308 V Visceral injury Vagina curriculum related to, 958t anatomy of, 260-261 postmortem examination of, 780 digital penetration of, 272-273 Visual evidence, 751-752 penetration of, pattern of injury with, 273, 284 Visual scheme, 453t-454t prepubertal, 289 Vitamin A poisoning, 127t Vaginal vestibule, 261 Vitamin C deficiency, 32-33 Vaginosis, bacterial, 297-298 Vitreous prophylaxis for, 294t postmortem examination of, 780-781 Validation of child, psychological, 432-433 in retinal hemorrhage, 43 Vascular disorder, 66t in Terson’s syndrome, 86 Vasculitis, hypersensitivity, 66t Vocal cord paralysis, 580 Verbal attack, 413 Voir dire, 723-724 Verbal evidence checklist, 712t Volunteer Verbal expression, enhancing, 437-438 religious, 547-548 Verbal recall, 350 school, 475-476 Vertebra, crushing of, 580 Vomiting, drug-related, 139t Vertebral body, subluxation of, 16t, 21 Vulnerability of child in religious institution, 541-550 Vertebral fracture, 20-21 Vulva, 260 Vicarious abuse situation, 415 Vulvar coitus, 261, 267, 273 Victim Vulvovaginitis, nonvenereal, 291t compliant, 523 cycle of violence and, 648-650 drawing body of, 458 of intimate partner violence, 642-643 W Walnut Street Baptist Church, 1004 law enforcement interview of, 670t, 671-673 Warfarin, 126t of Munchausen syndrome by proxy, 399-400 Warning about dangerous client, 715 Victim Identification Project, 520 Warning signs of Munchausen syndrome by proxy, 402-403 Victim support, 661 Warrant, search, 910-911 Victims of Child Abuse Act, 930 for unconscious victim, 903-904 Videocolposcopy, 248 Watchtower Society, 545 Videotaping, 419-420 Water deprivation, 129t, 139t, 141-142 Vietnamese medicine, 566 Water intoxication, 129t, 140-141, 793 Violence Welfare, public, as obstacle to partnership, 1018 consequences of, 357-359 Welfare system, child, 1003-1030. See also Child welfare system cultural difference and, 564-565 Whiplash injury, 40-49, 579. See also Shaken baby syndrome, domestic, 625-637. See also Intimate partner violence retinal hemorrhage in, 85-86 failure to thrive and, 202 White v Illinois, 762 intergenerational transmission of, 646-650 Whitlow, herpetic, 304 interpersonal, 639-658 WIC program, 179 child maltreatment, 645-646 Wilson, Mary Ellen, 1005 cycle of, 646-652 Witness intimate partner, 639-645 expert, 715. See also Expert testimony psychological maltreatment and, 322-323, 329-330 value of, 678 psychological response to, 411 victim as sexual abuse as, 414 preparation of, 732-734 Violent pornography, 415 in prosecution of sexual abuse case, 728-731 Viral infection, 291t Wood’s lamp, 874 hepatitis B Wooley, P.V., 1006 prophylaxis for, 294t Workforce issues in child welfare, 1022-1025 risk factors for, 301t in future, 1024-1025 human immunodeficiency, 294t, 299-303 policy implications of, 1024 human papillomavirus, 305-308 salaries as, 1023-1024 clinical presentation of, 306 shortage of social workers as, 1022-1023 overview of, 305-306 staff retention as, 1023-1024

1127 Child Maltreatment—A Clinical Guide

turnover rates as, 1023 Workload as obstacle to partnership, 1018-1019 World Studies of Abuse in the Family Environment project, 560 Wound, self-inflicted, 66t Wrist fracture, 20

Y Yes/no question, 243t

Z Zidovudine, as HIV prophylaxis, 303

1128 THIRD EDITION

G.W. Medical Publishing, Inc. St. Louis THIRD EDITION

Randell Alexander, MD, PhD, FAAP Professor of Pediatrics, and Chief Division of Child Protection and Forensic Pediatrics Department of Pediatrics University of Florida Jacksonville, Florida Professor of Pediatrics Morehouse School of Medicine Atlanta, Georgia

Angelo P. Giardino, MD, PhD, FAAP Associate Chair – Pediatrics Associate Physician-in-Chief/Vice President, Clinical Affairs St. Christopher’s Hospital for Children Professor in Pediatrics Drexel University College of Medicine Adjunct Professor of Pediatric Nursing LaSalle University School of Nursing Philadelphia, Pennsylvania

G.W. Medical Publishing, Inc. St. Louis FOREWORD Child maltreatment is a universal problem. Throughout the world there are parents, neighbors, friends, relatives, school or church workers, and others who fail to value children. Cases of maltreatment involve all socioeconomic classes; no one is exempt. With a scope this all-encompassing, how does one intervene effectively? These children and their families are best served when there is a collective effort by all who are called upon to respond to cases of child maltreatment. Those involved need to understand their respective roles and work together constructively. This means mutual respect and knowledge of how all parts of the system intertwine to provide the best protection for the child and family. The knowledge base in child maltreatment is expanding each day. Whereas in the 1970s there was a paucity of literature devoted to this field, last year there were hundreds of peer-reviewed journal articles written to inform professionals of new findings. These include articles about abuse or neglect as well as conditions that can be mistaken for maltreatment, issues arising in the context of child maltreatment cases, the economic consequences of adverse childhood experiences, the long-term psychological and medical consequences of maltreatment, and the legal aspects of this epidemic. The need for reliable information has never been greater. In this 2-volume set, child maltreatment is thoroughly described. Information necessary to understand the medical aspects of child maltreatment and the specific role of each team member is presented clearly. Included are chapters specific to healthcare providers, law enforcement personnel, child protection workers, attorneys, and others. The text attempts to reflect the most current and comprehensive knowledge base in each area. The third edition of Child Maltreatment: A Clinical Guide and Reference and A Comprehensive Photographic Reference Identifying Potential Child Abuse represents the collaboration of many dedicated professionals. Their overarching purposes are to educate every professional involved with children about the problem of maltreatment, to elucidate the approaches that have been successful, and to provide the best outcome possible for the involved children and their families. The practical applications presented are designed to provide all that is necessary to manage complex issues surrounding child maltreatment.

Robert M. Reece, MD Clinical Professor of Pediatrics Tufts University School of Medicine Visiting Professor of Pediatrics Dartmouth Medical School Editor, The Quarterly Update Norwich, Vermont

vii FOREWORD Recognition of child maltreatment is essential to safeguard the well-being of children. In 1961 Henry Kempe first brought this problem to world attention, yet it still remains largely unaccepted as an epidemic. The recognition of certain findings that lead to the identification of child maltreatment is vital in its detection, treatment, and prosecution. The Convention on the Rights of the Child guarantees children the right to a name, family, state, education, and safety, among others. However, parts of the world remain where children are not granted these basic rights. In many contexts, children are no more than commercial commodities, under the control of the adults around them. As such, they can be bought and sold and may be subjected to cruelties to enhance their commercial value, such as having their limbs cut off or their eyes blinded so they are more appealing as beggars. Harsh treatments of children may include inadequate food or shelter and punishments that threaten their life, physical integrity, or psychological well-being. Child trafficking for the purpose of enforced labor, soldiering, or prostitution is widely practiced. It affects not only nations with limited resources, but also those whose resources are almost limitless, since globalization facilitates children being traded on the world market. The facts and signs of maltreatment are plain to see in these cases, yet what is lacking is the will to name the problem and act against it. Cultural practices, lack of awareness, and systems that are geared solely to the economic gain of a few perpetuate the problem. Challenging these practices is a daunting undertaking that requires considerable resources, political will, and systemic change. In countries where child maltreatment is manifestly illegal and where sanctions exist against the abuser, the challenge of recognition is one of detection and identification. Instances of maltreatment can be hidden, or caregivers may claim that injuries are caused by accidental events or organic illnesses. The veracity of children who disclose abuse and the expertise of professionals who testify to the features of maltreatment may be called into question. The lack of rigorous experimental studies may be cited as evidence of the unreliability of child witnesses or the ingenuousness of forensic professionals. When lies, misunderstandings, or lack of sufficient knowledge or evidence prevent a clear distinction between abuse and a more benign explanation, it is the task of the responsible professional to make this distinction clear. However, when signs of maltreatment exist or they indicate that maltreatment is at least a strong possibility, professionals must make that case and advocate for measures to ensure the child’s safety. To increase the likelihood of reaching accurate conclusions, the professional must have a clear understanding of the harm attributable to maltreatment, of the mechanisms that cause injury, and of the signs that identify the lesions they produce. Reference to this atlas will contribute to the accurate identification of abuse and, in so doing, will contribute to the wider recognition of maltreatment as a violation of children’s rights, safety, and well-being. One of the benefits of globalization is that this knowledge and attitude may be disseminated so that the world can become a safer place for children everywhere.

Marcellina Mian, MDCM, FRCPC, FAAP Pediatrician, Suspected Child Abuse and Neglect (SCAN) Program Director, Undergraduate Medical Education Hospital for Sick Children Professor, Faculty of Medicine University of Toronto Toronto, Canada

ix PREFACE Child maltreatment evokes visual images, real or imagined, in the minds of pro- fessionals and the public. Some of these images are easily anticipated: the child with bruises, radiographs of broken bones, pictures of damaged hymens, and even the autopsy findings of the deceased child. Often they are horrific even though most child maltreatment cases are not the worst extremes. But many images are less obvious: the equipment used in child maltreatment cases, drawings by abused children, the many faces of neglect, or child maltreatment prevention images. Several of the photographic chapters in this book are relatively unique to child maltreatment texts. The goal of this photographic atlas is to give life to the content and process of child maltreatment in an attempt to expand upon the traditional ways in which child maltreatment is portrayed. One of the advantages of visual media is that they add exactness to some situations that cannot otherwise be easily described. Seeing a photograph of an abused child informs the viewer of more than notations on a line drawing of a figure. Too often, professionals attempt to communicate by words alone, believing that they are communicating the same point, but ultimately fail to completely grasp what the other is saying. This “parallel play” can have important consequences for abused children and those at risk. One example that may be familiar to many professionals is the shaking seen with shaken baby syndrome. Many in the public, and many beginning professionals, believe they know what the shaking looks like. This is belied by some of their questions (“Couldn’t it be accidental?” “Could it happen by jogging with a child in a backpack?”) that show that they are thinking of “jiggle baby syndrome” instead. This belief can persist for years as the professional imagines what experts are saying. Seeing an actual doll demonstration or computer animation depicting the extreme violence that actually occurs is much better for these professionals and perhaps the public. When juries see this, they know exactly what the expert is referring to and can make their own decisions without being ignorant of what is being proposed. Different modes of visualization can inform us in ways we are just beginning to explore. One visual aspect that should emerge more strongly in the future is the videotaping of a child who has been maltreated. While pictures of a child who is dirty, disheveled, and listless are very informative, it is even more revealing to watch a videotape of a child who is apathetic, has a sad affect, or may have various developmental delays. Still photographs of hymens have increased in quality both with an increase in photographic equipment detail and with greater experience of examiners, yet a static photograph of a genital exam evokes the question of whether a “finding” or “lack of finding” is an artifact of that instance in time. Even more importantly for the beginner, it can be hard to judge foreground and background— the problem most of us have when looking at aerial reconnaissance photographs. Put into motion, the examination looks like what we see with the real child. A product of the greater depth perception seen with motion parallax, visual perception is enhanced by retinal and visual cortex motion “detectors.” Another visual modality that will become increasingly informative will be the results of “nanny cams”—the home videotapes that are beginning to capture physical abuses committed by a person when it is thought no one is looking. In a future edition, we hope to begin to incorporate some of these video possibilities into the library of what is known. It is our hope that this atlas will be seen as providing an overview of the possibilities within the world of child maltreatment today. Read straight through, or used as a reference, the information contained within should help broaden horizons and help professionals in the field more clearly understand the many aspects of child maltreatment. Randell Alexander, MD, PhD, FAAP Atlanta, Georgia Angelo P. Giardino, MD, PhD, FAAP Philadelphia, Pennslyvania

xi REVIEWS OF THE THIRD EDITION Whether in an intensive care unit caring Angelo Giardino and his interdisciplinary This 3rd edition of Child Maltreatment for a child abuse victim, providing train- team of colleagues have continued to includes the very latest in research and ing, or testifying as an expert witness, there improve on an already exceptional col- clinical issues related to the injury and is one resource that I know I can cite as a lection of essays focused on the nature, exploitation of children. The editors have reliable reference, and that is Child extent and seriousness of child maltreat- gathered the best and the brightest authors Maltreatment. This is the most outstand- ment in the United States and other in the field to write the chapters and the ing text of its kind, and provides a economically advanced countries. In volumes contain essential knowledge for complete review with relevant references on addition to providing the reader with a students and clinicians. It is designed to be all aspects of the medical diagnosis and deep understanding of the complex forces a reference and resource for all agencies treatment of child abuse and neglect. I that contribute to child maltreatment, the that assist and manage child maltreatment recommend Child Maltreatment to all volume’s chapters offer clinicians and policy issues. members of an investigative multidiscipli- makers alike state-of-the-art guidance in nary team and consider it a mandatory preventing and caring for children who Ann Wolbert Burgess, RN, DNSc, CS resource in any medical, social science, or become victims of abuse and neglect. Dr. Boston College Connell School of criminal justice library. Giardino and his colleagues are to be Nursing Sharon Cooper, MD, FAAP congratulated for their pioneering Adjunct Associate Professor of Pediatrics contributions in helping to halt the current The third edition of this vital reference University of North Carolina School of epidemic of child maltreatment cases. designed for child maltreatment profes- Medicine Richard J. Estes, DSW, ACSW sionals contains new, cutting-edge, and Chapel Hill, North Carolina Professor evidence-based information. Comprised of Clinical Assistant Professor of Pediatrics Chair, Concentration in Social and 2 volumes with a total of 62 chapters, Uniformed Services University of Health Economic Development Child Maltreatment: A Clinical Guide Sciences Director, International Programs and Reference and A Comprehensive Bethesda, Maryland University of Pennsylvania School of Photographic Reference Identifying Chief, Developmental Pediatric Service Social Work Potential Child Abuse covers virtually Womack Army Medical Center Philadelphia, Pennsylvania every aspect of child physical, sexual, and Fort Bragg, North Carolina psychological abuse, child neglect, and service delivery systems that either This edition of Child Maltreatment This publication presents a comprehensive encounter or address child maltreatment. builds on the terrific start provided by This reference work should be in the look at the issues involved in cases of child James Monteleone with an expansion maltreatment, emphasizing the contem- library of every professional concerned with that is up-to-date, complete, and provides the problem of child maltreatment. porary importance of this subject together the best available information from an with reviewing the multidisciplinary extraordinary group of contributors. It is techniques for forensically detecting as well Kathleen Coulborn Faller, PhD, ACSW a “must,” not only for specialists in the Professor, School of Social Work as addressing the needs of victims of such field of child abuse and neglect, but for maltreatment. The text provides profes- Director, Family Assessment Clinic all health professionals who provide care University of Michigan sionals in the fields of law, social science to children. and the healthcare industry with invalu- Ann Arbor, Michigan able source materials when confronted Richard Krugman, MD with suspected child maltreatment. Dean of Medicine Faye Battiste-Otto, RN, SANE University of Colorado School of President, American Forensic Nurses Medicine Palm Springs, California Denver, Colorado

xiii CONTENTS IN BRIEF

PHYSICAL ABUSE CHAPTER 1: BRUISES AND OTHER SKIN INJURIES . . . . . 1 CHAPTER 2: BURNS, PART 1 ...... 67 BURNS, PART 2 ...... 121 CHAPTER 3: HEAD INJURIES ...... 137 CHAPTER 4: THORACOABDOMINAL TRAUMA ...... 173 CHAPTER 5: ORAL INJURIES ...... 191 CHAPTER 6: OPHTHALMOLOGY ...... 205 CHAPTER 7: RADIOLOGY ...... 213

SEXUAL ABUSE CHAPTER 8: SEXUAL ABUSE ...... 227 NEGLECT CHAPTER 9: NEGLECT ...... 265

CRIMINAL AND PSYCHOLOGICAL INVESTIGATIONS CHAPTER 10: THE MEDICAL EXAMINER ...... 287 CHAPTER 11: POLICE INVESTIGATIONS ...... 329 CHAPTER 12: DRAWING ...... 385

EVALUATION, EQUIPMENT, AND DEMONSTRATIONS CHAPTER 13: PHOTODOCUMENTATION ...... 415 CHAPTER 14: PHYSICAL ABUSE DOCUMENTATION . . . . 443 CHAPTER 15: EQUIPMENT FOR THE DOCUMENTATION OF SEXUAL ABUSE ...... 451 CHAPTER 16: DOCUMENTATION OF NEGLECT...... 455 CHAPTER 17: DEMONSTRATIONS ...... 465

RESOURCES FOR CHILD CARE PROFESSIONALS CHAPTER 18: PREVENTION ...... 469 CHAPTER 19: RESOURCES AND SETTINGS IN THE FIELD OF CHILD MALTREATMENT ...... 503

xv CONTENTS IN DETAIL

CHAPTER 1: BRUISES AND OTHER SKIN INJURIES Manifestations of Physical Maltreatment on the Skin: Impacts and Other Contacts ...... 1 Bruises ...... 2 Patterned Injuries ...... 14 Target Organs ...... 37 Multiple Injuries ...... 47 Strangulation ...... 55 Folk Medicine Practices ...... 57 Mimics of Abuse ...... 59 Accidential Injuries ...... 63

CHAPTER 2: BURNS, PART 1 Immersion Burns ...... 70 Stocking-Glove Pattern ...... 70 Multiple Injuries ...... 73 Scald Burns ...... 83 Contact Burns ...... 90 Hot Iron/Steam Iron ...... 90 Curling Iron ...... 92 Cigarettes ...... 97 Fireworks ...... 101 Space Heater/Radiator ...... 102 Report from a Third Party ...... 104 On-site Investigation of Multiple Burn Surfaces ...... 105 Wringer Washer ...... 106 Multiple Burns ...... 107 Multiple Injuries ...... 108 Branding ...... 111 Healed Burns ...... 111 Flame Burns ...... 112 Chemical Burns ...... 112 Electrical Burns ...... 113 Frostbite ...... 113 Mimics ...... 114 Senna ...... 114 Accidental Burns ...... 115 Contact Burns ...... 115 Multiple Injuries ...... 116 Spills ...... 117 Immersion ...... 119 Chemical Reactions ...... 119

CHAPTER 2: BURNS, PART 2 Immersion Burns ...... 121

xvii Contents in Detail

Delay in Care ...... 121 Extensive Bathtub Burns ...... 122 Perineal Burns ...... 124 Stocking-Glove Pattern Burns ...... 124 Healing Immersion Burns ...... 125 Immersion Burn Scar ...... 126 “Doughnut” Burn Pattern ...... 126 Water Lines Shown by Burns ...... 127 Scarring ...... 128 Water Burn Reported as Chemical Burn ...... 130 Scalding ...... 132 Pattern with Scalding ...... 132 Miscellaneous Burn Cases ...... 134 Multiple Burns ...... 134 Burns to Brand a Child ...... 135 Contact With Hot Stove ...... 135 Curling Iron Burn ...... 136

CHAPTER 3: HEAD INJURIES Head Trauma ...... 139

CHAPTER 4: THORACOABDOMINAL TRAUMA Chest Injuries ...... 174 Lung Injuries ...... 174 Ribs ...... 175 Contusions ...... 177 Abdominal Injuries ...... 178 Liver Laceration ...... 178 Duodenum ...... 179 Small Intestine ...... 180 Ruptured Blood Vessels/Aorta ...... 181 Multiple Injuries Attributed to CPR ...... 182 Multiple Injuries With Insufficient History ...... 183 Imaging ...... 185 Computed Tomography (CT) Scans ...... 185 Liver Laceration ...... 185 Abdominal Trauma ...... 186 Upper Gastrointestinal (GI) Studies ...... 187 Duodenal Hematoma ...... 187 Chest Radiograph ...... 188 Radiograph of Ribs ...... 188 Radiograph of Humerus ...... 188 Radiograph Showing Fractures ...... 188 Multiple Studies ...... 189

CHAPTER 5: ORAL INJURIES Avulsion ...... 194 Accidental Injury ...... 194 Multiple Inflicted Injuries ...... 194 Burns ...... 194 Electrical Burn ...... 194 Branding of Multiple Surfaces ...... 195 Bruises ...... 195 Pattern Injuries ...... 196 Bite Marks ...... 197 xviii Contents in Detail

Animal Bite Marks ...... 197 Human Bite Marks ...... 198 Sexual Abuse ...... 203 Multiple Injuries ...... 203 Ecchymosis ...... 204 Neglect ...... 204 Caries ...... 204

CHAPTER 6: OPHTHALMOLOGY Unresponsive Victim of SBS ...... 206 Seizures Caused by SBS ...... 208 Hematoma with SBS ...... 209 Retinal and Macular Hemorrhages ...... 210 Papilledema ...... 210 Retinal Hemorrhage ...... 211 Residual Findings ...... 212

CHAPTER 7: RADIOLOGY Spiral Femoral Fractures ...... 216 Supercondylar Humeral Fracture ...... 216 Multiple Fractures of Ribs, Clavicle, and Left Elbow ...... 217 Bucket-Handle Fracture ...... 218 Chronic Fracture ...... 219 Specific and Less Specific Fractures for Abuse Diagnosis ...... 220 Multiple Fractures of Various Ages ...... 220 Stomping Injuries ...... 221 Multiple Rib Fractures of Various Ages ...... 221 Rib Fractures on a Nuclear Medicine Bone Scan ...... 222 Punching Injuries ...... 222 Ruptured Pancreas ...... 223 Death From Stomping ...... 224 Common Injuries Assocated With Abuse ...... 225

CHAPTER 8: SEXUAL ABUSE Techniques and Basic Skills ...... 228 Hymenal Configurations ...... 230 Findings Confused With Abuse ...... 233 Imperforate Hymen ...... 233 Lichen Sclerosis ...... 233 Prolapsed Uterus ...... 234 Failure of Midline Fusion ...... 234 Labial Fusion ...... 234 Straddle Injury ...... 235 Vaginal Duplication ...... 235 Vitiligo ...... 235 Foreign Body ...... 236 Hymenal Projection ...... 236 External Hymenal Midline ...... 237 Extensive Labial Fusion ...... 237 Failed Midline Fusion ...... 237 Possible Foreign Body ...... 238 Lichen Sclerosis Causing Bleeding ...... 239 Labial Bruising ...... 239 Duplication of Reproductive Structures ...... 239 Pinworm ...... 240

xix Contents in Detail

Hemangioma ...... 240 Perianal Vitiligo ...... 240 Normal Findings ...... 241 Crescentic Hymen ...... 241 Annular Hymen ...... 241 Large Urethral Opening Above Normal Hymen ...... 241 Normal Intact Hymen ...... 242 Anal Tag ...... 242 Normal Intact Annular Hymen ...... 242 Intravaginal Ridge ...... 243 Normal Examination ...... 243 Normal Anal Findings ...... 243 Thickened Crescentic Hymen ...... 243 Circumferential or Annular Hymen ...... 244 Anterior Anal Venous Pooling ...... 244 Extensive Anal Pooling ...... 244 Midline White Line ...... 245 Normal Examination After Sexual Assault ...... 245 Smooth Avascular Posterior Area ...... 245 Hymenal Projection ...... 245 Integrity of Hymen ...... 246 Hymenal Mound ...... 246 Anterior Intravaginal Ridge ...... 246 Knee-Chest Position ...... 247 Intact Posterior Rim ...... 247 Prominent Urethral Support Structures ...... 247 Hymenal Tag ...... 248 Normal Posterior Hymenal Rim ...... 248 Hymenal Projection ...... 248 Intravaginal Rugae and Normal Hymen ...... 248 Estrogenized Hymen in Abused Girl ...... 249 Normal Hymenal Mound ...... 249 Posterior Mound with Cleft ...... 249 Possible Precocious Puberty ...... 249 Cribriform Hymen ...... 250 Estrogenization and Intravaginal Rugae ...... 250 Vascularization ...... 250 Examination With and Without Traction ...... 251 Hymenal Pit ...... 251 Normal Cribriform Hymen in Alleged Abuse ...... 251 Penetration ...... 252 Acute Findings ...... 253 Hematoma and Hymenal Tear ...... 253 Partial Healing After Transection of the Hymen ...... 253 Anal Tears ...... 253 Lacerations ...... 254 Unexplained Genital Bleeding ...... 255 Acute Penetration ...... 256 Traumatic Superficial Hymenal Laceration ...... 256 Anal Laceration ...... 256 Laceration With Bruising ...... 257 Perianal Laceration ...... 257 Acute Laceration After Penile Penetration ...... 257 Vaginal Bleeding After Penile Penetration ...... 258 Labial Intercourse ...... 258 xx Contents in Detail

Straddle Injury-Related Bruising ...... 258 Alleged Rape ...... 259 Perianal Bruising ...... 259 Bruising of Penis ...... 259 Burned Penis ...... 259 Perianal Laceration Caused by Penetration ...... 259 Accidental Anal Hematoma ...... 260 Sexually Transmitted Diseases ...... 260 Perianal Herpes ...... 260 Condyloma Acuminata ...... 260 Hemorrhagic Herpes ...... 261 Scrotal Condyloma Acuminata ...... 261 Cylindrical Perianal Condylomata ...... 261 Perianal Streptococcal Infection ...... 262 Penile Lichen Planus ...... 262 Flat Warts ...... 262 Molluscum Contagiosum ...... 263 Old Injuries ...... 263 History of Penile Penetration ...... 263 Previous Vaginal Penetration ...... 263 Digital Penetration ...... 264 Healed Transection ...... 264

CHAPTER 9: NEGLECT Supervisory Neglect ...... 266 Environmental Neglect ...... 269 Medical Neglect ...... 274 Nutritional Neglect ...... 275

CHAPTER 10: THE MEDICAL EXAMINER Crime Scene Reconstruction ...... 288 Suspicious Injuries ...... 290 Penile Laceration ...... 290 Squeezing ...... 291 Nonabusive Skin Lesions ...... 293 Skin Discoloration ...... 295 Bite Marks ...... 297 Evidence of Ongoing Maltreatment ...... 300 Multiple Fractures ...... 304 Abused Siblings ...... 305 Beating ...... 308 Distinctive Injuries ...... 311 Sexual Assault ...... 313 Deaths ...... 314 Infant Found Buried ...... 314 Starvation ...... 316 Impaction ...... 319 Severe Neglect ...... 320 Asphyxia ...... 320 Multiple Bruises ...... 321 Oral Injuries ...... 322 Teenage Death ...... 323 Forced Feeding ...... 323 Gunshot Wounds ...... 324 Bruising with Closed Head Injury ...... 324

xxi Contents in Detail

Soft Tissue Injuries ...... 325 Rib Fractures ...... 325 Blunt Abdominal Trauma ...... 326 Blunt Chest Trauma ...... 326 Closed Head Injury Deaths ...... 327

CHAPTER 11: POLICE INVESTIGATIONS Reports of Child Maltreatment ...... 330 Evidence and Victim’s Statements ...... 338 Differentiating Between Inflicted and Accidental Injuries ...... 340 Thorough Documentation and Investigation of the Scene ...... 346

CHAPTER 12: DRAWING Reflective Representations ...... 388 Variant Artistic Expression ...... 388 Client’s Attitudes ...... 388 Aspects Charts ...... 389 Feeling Helplessness and Worry ...... 390 Teen’s Feelings of Hopelessness and Confusion...... 390 Visual Environment Cueing ...... 391 Concern for Another...... 391 Illness and Death...... 392 Emotional Attachment ...... 392 Insight for Therapeutic Intervention ...... 392 Prenatal Memory ...... 392 Three-dimensional Representations ...... 393 World Events...... 394 September 11...... 394 Foundation for Storytelling...... 394 Avoiding Abuse ...... 394 Sexual Abuse ...... 395 Regression and Agitation Signaling Sexual Abuse ...... 395 Sexual Abuse By a Grandfather...... 395 Hypervigilance and Fear After Sexual Assault ...... 396 Relating Story of Abuse...... 396 Internalization of Emotions and Guilt ...... 397 Working Through Therapeutic Stages...... 398 Exposure to Sexual Activity...... 399 Child’s View of Adult’s Involvement in Illicit Sexual Activity . . . . . 399 Interpersonal Violence ...... 399 Anger, Hostility, and Aggression ...... 399 Depictions of Abuse Beginning Before Conscious Memories and Through Intergration and Awareness ...... 400 Witness to Gunfight...... 402 Progression From Abuse To Killing the Abuser ...... 403 Drugs and Alcohol ...... 408 Death of Adult ...... 408 Child’s Understanding of Aspects of Behavior ...... 408 Sudden Traumatic Deaths ...... 409 Memories of Deceased ...... 409 Multiple Witnesses of the Same Event ...... 409 Hypervigilant Attention After Brother’s Murder...... 410 Generalized Fear for Safety and Bodily Integrity ...... 411 Hypervigilance and Fear After Brother’s Murder ...... 412 Shaken Baby Syndrome...... 412 xxii Contents in Detail

Fear and Sadness After Infant’s Death...... 412 Witness To Death of Infant Sister ...... 413 Funerals ...... 414 Anxiety and Agitation ...... 414 Funeral of Uncle ...... 414

CHAPTER 13: PHOTODUCUMENTATION Facial Findings ...... 418 Possible Bruising ...... 419 Faded and Fresh Bruising ...... 420 Lesion Differentiation ...... 421 Scleral Hemorrhage and Bruising ...... 422 Multiple Injuries ...... 423 Facial Brusing ...... 424 Grab Marks ...... 425 Magnification ...... 426 Lash Marks ...... 427 Hot Water Burn Injury ...... 428 Burn Injury ...... 429 Burn Injury and Implement ...... 430 Abdominal Bruise ...... 431 Wrist Splint ...... 431 Fracture ...... 432 Facial Injuries ...... 434 Injury From a Fall ...... 435 Genetal Injury ...... 436 Still Images from Digital Video ...... 437 Genetial Injury ...... 438 LR Setup ...... 438 Postmortem Rectal Image ...... 439 Colposcopic Photographs ...... 439 Use of Video ...... 440 Genital Injury ...... 441 Appendix 13-1: Additional Resources ...... 442

CHAPTER 14: PHYSICAL ABUSE DOCUMENTATION Eye Examination ...... 443 Cameras ...... 443 Investigational Tools ...... 444 Radiology Evaluation ...... 447

CHAPTER 15: EQUIPMENT FOR THE DOCUMENTATION OF SEXUAL ABUSE

CHAPTER 16: DOCUMENTATION OF NEGLECT Normative Charts ...... 456 Using Charts ...... 460

CHAPTER 17: DEMONSTRATIONS

CHAPTER 18: PREVENTION The Promise of Prevention: Challenges and Approaches ...... 469 Challenges in Delivery of Prevention Programs ...... 469 Range of Prevention Programs ...... 470 New Directions in Prevention ...... 471

xxiii Contents in Detail

Prevention Strategies ...... 472 Public Awareness and Education Prevention Messages ...... 472 Sexual Abuse ...... 472 Warning Signs ...... 472 Massachusetts—Media Campaign ...... 473 Georgia—Adult Responsibility Advertisement ...... 473 Georgia—Preserving Childhood ...... 474 Physical and Emotional Abuse and Neglect ...... 474 Shaken Baby Syndrome ...... 475 Elijah’s Story ...... 475 General Prevention Messages ...... 475 Blue Ribbon Symbol ...... 476 Missouri—Car Safety ...... 476 Missouri—Bullying ...... 476 Advocacy ...... 476 Building Public and Political Will for Prevention ...... 476 Fight Crime ...... 477 Nurturing Environments ...... 477 Child Abuse Prevention Month ...... 478 Prioritizing ...... 478 Louisiana—Advocacy Summits ...... 479 Louisiana—Advocacy Platform ...... 479 Authentic Voices ...... 479 Parents Anonymous Leadership ...... 480 Professional Education ...... 481 Emerging Practices ...... 481 Standards for Prevention Programs ...... 481 Parent Training ...... 481 Advice to Professionals ...... 482 Right on Course ...... 482 Spider-Man and an Approach to Bullying ...... 482 Colleagues for Children ...... 483 Missouri—Mandated Reporters ...... 483 The Quarterly Update: Reviews of Current Child Abuse Medical Research . 483 American Professional Society on the Abuse of Children Publications . . . 483 Conferences and Training to Equip Professionals to Work in Prevention . . 485 Shared Leadership ...... 485 Programs to Support and Educate Parents ...... 485 Universal Parental Support Programs ...... 485 Georgia—Crying Program ...... 485 Stages Crying Program ...... 486 Period of PURPLE Crying ...... 486 Helpline ...... 487 New Parent Materials ...... 488 Circle of Parents ...... 488 Parents Anonymous Groups ...... 488 Programs Targeting High-Risk Parents ...... 489 Hawaii—Hana Like Home Visitor Program ...... 489 Healthy Families Georgia ...... 490 Family Connections ...... 490 Oklahoma—SafeCare Program ...... 491 Project Healthy Grandparents Program ...... 492 Aid to Children of Imprisoned Mothers ...... 492 Iowa—First Steps ...... 492 Iowa—Stork’s Nest Program ...... 492 xxiv Contents in Detail

Programs Targeting Fathers ...... 493 Fathers and Children Together ...... 493 Georgia—Fathers Program ...... 494 Iowa—Fathers Program ...... 494 Spider-Man Fathers Resource ...... 494 Resources to Help Parents Keep Children Safe ...... 494 How to Help Kids Stay Safe ...... 494 What Do I Say Now? ...... 494 Before You Leave Your Kids with Your Boyfriend ...... 494 Children Home Alone ...... 495 Report Card Time ...... 495 Personal Safety and Support/Education Programs for Children ...... 495 Parents Anonymous Children’s Program ...... 495 Circle of Parents Children’s Program ...... 495 Georgia—Need to Talk Helpline ...... 496 Aid to Children of Imprisoned Mothers ...... 496 Project Healthy Grandparents—Children’s Program ...... 496 Programs to Teach Violence Prevention Skills ...... 496 Second Step Violence Prevention Program ...... 497 Violence Prevention Skills ...... 497 Steps to Respect Kit ...... 497 Personal Safety Curriculum ...... 497 Spider-Man Personal Safety Material ...... 497 QuickThink ...... 497 HOPE! Drama Troupe ...... 497 Woven Word Family Book ...... 497

CHAPTER 19: RESOURCES AND SETTINGS IN THE FIELD OF CHILD MALTREATMENT Professional Organizations ...... 503 National Clearinghouse on Child Abuse and Neglect ...... 503 American Professional Society on the Abuse of Children Information . . 503 International Society for Prevention of Child Abuse and Neglect . . . 504 Prevent Child Abuse America ...... 505 National Children’s Alliance ...... 505 National Center on Shaken Baby Syndrome ...... 505 Conferences ...... 506 ISPCANConference ...... 506 APSAC Conference ...... 506 Children’s Hospital of San Diego Conference ...... 506 National Conference on Child Abuse and Neglect ...... 507 Crimes Against Children Conference ...... 507 Huntsville Conference ...... 507 Conference on Shaken Baby Syndrome ...... 508 Publications ...... 508 The Quaterly Update ...... 508 Child Maltreatment ...... 508 APSACAdvisor ...... 509 APSAC Guidelines ...... 509 International Journal of Child Abuse & Neglect ...... 510 The Link ...... 510 Settings ...... 510 CACs ...... 510 Reception to the Center ...... 511 The Examination ...... 511

xxv Contents in Detail

The Interview ...... 512 Therapy ...... 512 Meetings ...... 513 Storage ...... 514 Estonian Child Sexual Abuse Interview Center, Tartu, Estonia . . . 514 Courtrooms ...... 515 Courtroom Organization ...... 516

xxvi THIRD EDITION

G.W. Medical Publishing, Inc. St. Louis 1 Chapter

BRUISES AND OTHER SKIN INJURIES Charles Felzen Johnson, MD

MANIFESTATIONS OF PHYSICAL MALTREATMENT ON THE SKIN: IMPACTS AND OTHER CONTACTS Parents’ or caretakers’ reactions to unwanted behaviors from a child may be mani- fested by an unplanned and immediate physical or verbal attack on the child. If the attack does not result in any persistent tissue injuries, such as a bruise, there will be no record of the injury. Consequently, the injury may be considered insignificant or not serious enough to constitute a report of suspected abuse. For example, a slap to the face should be considered inappropriate because of the vulnerability of the delicate structures of the face and the impact’s potential to harm the brain. Erythema from a slap to the face will fade in minutes to hours depending on the force used. The objects used in a physical attack generally are readily available. The hand requires no preparation for an attack on a child. It can be used in an open manner as a slap or in a fist as a punch. The hand can grab, pinch, and twist the skin. Nails can gouge and scratch. Common objects around the house varying in size and shape can be wielded by hand. Depending on where and how they impact the skin, the marks they leave may be in silhouette or outline form. For example, a flat object impacting the buttocks, lower back, or chest will leave varying marks on each surface, such as a round mark on the buttocks, a row of round marks on the lower back from the spinous processes that are under the skin of the back, or a series of lines mirroring the underlying ribs. Other parts of the body may be used to injure a child. Mouths may be used to bite or suck on a child’s skin. Occasionally, a knee may kick or strike a child or arms may be used to crush a child against a caretaker’s chest. Impacts to areas of the body where bones are not immediately under the skin, such as the abdomen, may not show topical marks. Parents may apply folk remedies to the skin that result in tissue injury. Physicians who care for children must be familiar with the marks left by various objects that indicate abuse and those skin conditions that may mimic intentional injury.

1 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

BRUISES

Case Study 1-1 This boy of 2 years and 7 months was removed from his home because of neglect. The mother is HIV positive. The caseworker saw bruises on the child’s face and referred him for evaluation. During the examination the child had a grand mal seizure.

Figures 1-1-a and b. 2 cm oval brown bruises on both sides of the face, lacerations on both ear lobes, and red abrasions are seen on the lower lip and under the left chin. Figure 1-1-a Figure 1-1-c. The pattern of the bruises is best seen by applying circles over the bruises in a computer graphics program. The pattern is compatible with blunt impact from fingertips. The other injuries are indicated with applied arrows.

Figure 1-1-d. Further examination revealed bruises on the hips, penis, and scrotum. It may be difficult to determine if bruises to the genitalia result from a physical or sexual assault. The marks on the penis and scrotum are likely to be from pinching. The cause of the hip bruises is unknown. Bruises from impacts are more likely to manifest on the hips because they, like the shins, brow, chin, and forehead, are areas where the skin is close to underlying bone. Figure 1-1-b Figure 1-1-e. The examination for findings of physical abuse should include thorough examination of the genitalia and anus. In this child, new fissures surround the anus. The perianal area is erythematous. A red and blue bruise is seen on the right buttock. This boy has been anally penetrated.

Review of the chart revealed a seizure dis- order on medication. Blood studies were ordered to determine if the child was being given prescribed medication. A failure to give prescribed medication should be reported as medical neglect. A head CT scan was normal. Bruises on different surfaces cannot be compared with each other for dating. The brown bruises on the cheeks may have been older than the red purple Figure 1-1-c Figure 1-1-d bruises seen on other body parts. It is pos- sible that the injuries to the cheeks and hips occurred in the process of attempted rectal penetration. The fingertip marks on the face are likely to have been caused as a way to hold the child still. They are not slap marks. (See Figure 1-17 for an example of slap marks.) To determine if the marks on the scrotum and penis were from sexual abuse, one would need to know the intent of the perpetrator. Suspect physical abuse and sexual abuse were reported. The child was too young to interview. There were no other children in the home.

Figure 1-1-e

2 2 Chapter

BURNS PART 1 Matt Young, MD

Children who are burned abusively are marked or branded with the outward manifestation of parental violence, emotional imbalance, impulsivity, educational and cultural deprivation, and poverty. Intentionally burning a child is controlled and pre- meditated. Abusive burns cause both physical and emotional trauma at the time of the incident, and often produce long-term physical and psychological scarring. Abusers who burn typically are educationally deprived, abuse women (if male), and may be isolated, suspicious, rigid, dependent, or immature. They often display more concern for themselves than the child, frequently show little remorse, and are evasive and contradictory. They generally do not volunteer information, seldom visit the child in the hospital, and rarely ask questions about the child’s condition. By contrast, parents whose child is accidentally burned usually blame themselves for a lack of supervision and may display a profound sense of guilt. The 6 categories of burn injuries are: flame, scald, contact, electrical, chemical, and radiation (eg, sunburn from ultraviolet radiation). Abusive burns generally cluster in the scald and contact categories, although there are reports of other types of burns. Children’s skin is much thinner than adult skin, so serious burning occurs more rapidly and at lower temperatures. Electrical burns can be deceptive since trauma may not always be outwardly apparent. Electricity follows the path of least resistance, and skin is a natural resistor to electrical flow. Nerves, muscles, and blood vessels, however, are good conductors and more susceptible to electrical trauma. Electrical flash burns are caused when the current is shorted, producing a very brief, high- intensity fireball that causes thermal injury. Flash burns char the superficial layers of skin, but usually do not cause destruction of deep tissues. Medical treatment of the injury must be the first priority with burn patients. Once these needs are met, efforts can be directed toward obtaining an accurate history from witnesses and family members. Investigators must carefully outline the time, nature, extent, and location where the burn occurred. It also vital that medical personnel note the exact shape, depth, and margins of all wounds, including all body parts involved. Immediate attention to these details can prove to be invaluable when drawing a later distinction between an abusive and accidental injury. Children need to feel like they are in a safe environment and they are not going to be hurt again. It is best to begin by asking them general questions, such as: How did you get hurt? Specific questions should be asked only after they have had the opportunity to tell their story. Another important question to ask is: Is there anything that you are not supposed to tell me? Another important factor to consider in the examination of a child is the length of time it takes for a second- or third-degree burn to occur relative to the temperature of a given liquid (Figure 2-1). Consideration of time and surface temperature in determining the causation of burns can indicate whether or not the burns are abusive

67 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

Abuse Accidental Abuse Accidental

Head Head 6% 32%

Posterior Bilateral Anterior Bilateral Tr u n k Hands Tr u n k Hands 6% 14% 18% 18% 41% 8% One One Hand Hand Buttocks 35% 33% 35% 7% Genitalia 24% 5%

Foot One Foot 41% 12% Bilateral Feet 4% (All cases of feet Figure 2-2 burns were Bilateral)

or accidental. The location of the burn on the surface of the child’s body is also key information when determining if injuries are the result of abuse (Figure 2-2). It is significant to note that the head and thoracoabdominal region are more likely to be involved in accidental burns, whereas the buttocks, Figure 2-1 genitalia, bilateral hand, and bilateral feet burns are much more likely to be related to abuse. Figure 2-1. Length of time required for second- and third-degree burns to occur Accidental scald burns of the trunk usually involve the anterior surface of the body. when exposed to liquids of varying temperatures, reinforcing the relative In most cases, hot liquid is spilled onto children when they pull a tablecloth edge, importance of time and surface temperature causing a hot liquid to spill over and burn them from the table. Gravity causes a in the causation of cutaneous burns. linear burn pattern and clothing affects the burn pattern and severity as it insulates Figure 2-2. Diagram of anterior and the skin. Hot liquid may pool in the diaper area resulting in an unusual burn pattern. posterior body surfaces with the results of the Grossman Burn Center Study that was In a physical exam, the most common indicators of abuse are burns to the genitalia presented at the American Burn Association and buttocks, mirror image burns of the extremities, in addition to bruises, welts, or Annual Meeting in 1999. It represents the fractures. The most important determination to make in distinguishing between frequency of involvement of different body parts with a comparison between accidental accidental and inflicted burns is whether the pattern of the burn is consistent with and abusive burns. the history given by caregivers. When a child presents with a burn and one or more of the following factors are found, the evaluator should consider abuse: 1. Multiple hematomas or scars in various stages of healing 2. Concurrent injuries or evidence of neglect such as malnutrition and failure to thrive (Especially suspicious are bone injuries such as old rib fractures and distal tibial, metaphyseal, or spiral fractures.) 3. History of multiple prior hospitalizations for “accidental” traumas 4. An inexplicable delay between time of injury and first attempt to obtain medical attention (In some cases, if the parent has medical training, such as an RN or MD, the delay may be because the parents initially tried to care for the burn on their own.) 5. Burns appearing older than the alleged day of the accident, similarly indicating ambivalence about seeking care due to the possible risk of exposure of the abuse 6. An account of the incident not consistent with the age or ability of the child

68 3 Chapter

HEAD INJURIES Sam Gulino, MD Wilbur Smith, MD Swati Shah-Mody, MD

Abusive head injury has several synonyms, including shaken baby syndrome, shake impact syndrome, and non-accidental brain trauma. Regardless of the label, abusive head injury frequently results in serious and permanent brain damage. The forces to which the infant’s brains are subjected are severe. The prevalence of abusive head injury is highest in children younger than two years of age, probably because the size of an older infant makes it difficult to create the extreme forces necessary to inflict such severe injury to the brain and its coverings. When evaluating abusive head injury, it is best to consider each injury individually since it involves the internal layers of tissue as well as those surrounding the brain. While this is a logical approach to describing the injuries, it is important to recognize that multiple anatomical areas of injury are the rule, not the exception. External to the brain, the scalp is often the site of a subgaleal hemorrhage after impact. Hemorrhage into the scalp creates the proverbial “egg” on the scalp. The subgaleal space is a large potential space; therefore, the blood often flows into a dependent region. This explains why the palpable or visible bump is not always in the region of the trauma. Unless the child has a bleeding disorder or some other abnormality, the presence of a subgaleal hematoma always suggests that there was an impact injury. There is another, less common variant of scalp injury: the cephal- hematoma, which is a hemorrhage in the subperiosteal space, external to the bone but localized anatomically to the bone since it is confined by the periosteial layer of each bone of the skull. Cephalhematomas are rarely seen in child abuse and always remain local to the area of hemorrhage or impact. The skull serves to protect the brain and is often fractured if the injury involves impact. Skull fractures typically associated with abusive head injury are similar to those due to high velocity impact. These fractures are long (longer than 5 cm), stellate (many limbs from one point of impact) or diastatic (the edges of the fracture are widely spread). It is possible to have skull fracture from a short fall. In rare cases, some overlap of features between high impact and short fall injuries may occur; however, the presence of long, stellate, or diastatic fractures should lead to enhanced suspicion if they are ascribed to a short fall. The epidural hematoma is an unusual injury in child abuse. This type of hematoma occurs because of bleeding, usually arterial, into the epidural space between the inner table of the skull and the dura mater. This lesion is classically associated with a lucid interval and skull fracture. The theory of the lucid interval is that the initial impact causes the fracture and concussion, rendering the victim unconscious. The subsequent bleeding from ruptured branches of the middle meningeal artery then causes a hematoma, which subsequently causes further deterioration of mental status after the patient stabilizes from the concussion. The subdural hematoma (SDH) is a hallmark of abusive head inury and is the most frequently diagnosed intracranial injury in child abuse. Bleeding in the subdural

137 Chapter 3: Head Injuries

HEAD TRAUMA

Case Study 3-1 This 5-month-old girl was beaten to death with a broom by her father in a domestic argument with her mother. These photographs were taken at autopsy.

Figures 3-1-a, b, c, and d. Bruises are seen on the face. Pattern injuries, especially on the right eye, are indicative of a broom. Frequently, subgaleal hemorrhage (blood beneath the scalp) is seen with external injuries such as these. If the subgaleal bleeding is extensive enough, it may be seen on CT scans or at autopsy upon reflecting the scalp backwards.

Figure 3-1-a

Figure 3-1-c

Figure 3-1-b

Figure 3-1-d

139 INDEX from radio antenna, 308 A in sexual assault, 313 A Child Is Helpless —You Are Not, 475 on thigh, 306 Abandonment, 272 Abscess Abdomen. See also Abdominal injury of foot, 320 bite marks on, 202, 297-298 retropharyngeal, 320 bruise on, 52 of teeth, 204 in infant, 13 Abused siblings, 305-308 photodocumentation of, 431 Accidental burn. See also Accidental injury in toddler, 9 chemical reaction, 119 burn on contact cigarette, 100 of arm, 115-116 contact, 110 of hand, 115-116 curling iron, 92 of shoulder, 115 scald, 89 immersion, 119 distended, 319 scald, 334-335 protuberant, 279, 280 from space heater, 116 mark on from spill human bite, 202 on arm, 118 linear, 31 on back, 117 loop, 46 on chest, 118-119 in starvation death, 318 on face, 117 Abdominal injury, 178-189. See also Abdomen on neck, 118 attributed to CPR, 182 on thigh, 117 computed tomography of, 185-186, 189, 222 Accidental ingestion of medication, 268 death from, 326 Accidental injury to duodenum, 179 anal hematoma from, 260 with insufficient histories, 183-184 to arm, 64 kicks causing, 203 avulsion, oral, 194 liver laceration as, 178 brow laceration as, 63 overview of, 173 to elbow, 64 radiography of, 187-189 to femur, 214 ruptured blood vessels from, 181 near strangulation as, 56 to small intestine, 180 to neck, 64 from stomping, 180, 221 police investigation of, 333 ABFO Bitemark Scale ruler, 445 scrotal, 65 Abrasion to shoulder, 64 accidental, 67 to thorax, 64 on back, 305-306 vehicular, 153 on buttocks, 305-306 wringer, 21 on cheek, 34 Adolescent on chin, 34 alleged rape of, 259 corneal, 46 beating of, 35, 336 linear, 48 with radio antenna, 308-310 multiple, 26-27, 64, 88 belt injury to, 19 near eye, 34 death of, 323

521 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

eye and mouth injury to, 42 intact, 242 fist and kick injury to, 7 pubertal changes in, 231 genital injury of, 438 Anoxia from suffocation, 210 hematoma in, 253 Anterior anal venous pooling, 244 hymen in Anterior intravaginal ridge, 246 intact, 242 Antibullying campaign, 476 integrity of, 246 Anus. See also Anal entries laceration of, 256 condyloma acuminata of, 260 tear of, 253 fissures around, 2 hymenal projection in, 236 friability of, 435 intravaginal rugae in, 250 herpes infection of, 260 multiple loop and linear marks on, 35 laceration of, 36, 256 penetration of, 256 normal, 243 laceration after, 257 puncture wound of, 49 sexual assault of, 313 tear of, 49, 253 stick injury to eye of, 35 Anxiety, drawing showing, 414 stretch marks on, 421 Aorta, rupture of, 181 Advertising campaign to prevention child abuse, 472-476 APSAC. See American Professional Society on the Abuse of Advice to Professionals on Child Sexual Abuse Prevention Children Programs for Preschoolers and Elementary-Aged Children, APSAC Advisor, 484-485, 509 482 APSAC Practice Guidelines, 509 Advocacy center, 505, 510-514 Arm Advocacy in prevention programs, 476-480 accidental burn of, 118 Age accidental injury to, 64 of biter, 15, 192 allergic reaction on, 20 of fracture, 215, 220-221 bite mark on, 199-200, 203, 297-299, 307 Aggression, drawing depicting, 399 brand on, 111 Agitation, drawing depicting bruise on, 4, 33, 303 at funeral, 414 cigarette burn of, 98 from sexual abuse, 395 contact burn of, 91, 109-110, 116 Aid to Children of Imprisoned Mothers, 492, 496 curling iron burn on, 93, 115 Airway obstruction from alimentary bolus, 323 documentation of injury of, 449 Alcohol burn, 58 flame burns on, 342 Alcohol-related abuse, drawing of, 408 grab marks on, 183, 341, 349 Alimentary bolus, obstruction from, 323 healing burn on, 98 Alleged fall immersion burn of, 128-129 from car seat, 162 linear scar on, 22 from crib, 32-33 patterned injury on, 15 crime scene of, 288-289 restraint-related injury to, 47 documentation and, 445 scalding injury to, 86, 133 epidural hematoma in, 162 scarring to, 128-129 from high chair, 22 self-inflicted scratch to, 312 injury not consistent with, 6, 8, 14, 182, 344 stocking-glove burn pattern on, 72 down stairs, 6, 8, 34, 37, 182 wringer injury to, 21, 106 Alleged rape, 259 Armpit, bite marks near, 341 Allergic reaction to rubber bands, 20 Artifact, epidural hemorrhage as, 172 American Burn Association, 68 Artwork. See Drawing American Professional Society on the Abuse of Children, Aspects chart, 389-390 503-504 Asphyxiation conference of, 506 death from, 28, 320-321 publications of, 483-485, 508-509 of infant, 321 Anal hematoma, accidental, 260. See also Anus of toddler, 320 Anal intercourse, 36, 244-245, 252, 259 Aspiration, pepper, 174 Anal tag, 242 Assault, sexual. See Sexual abuse Anal venous pooling, 244 Atlanta, Georgia, juvenile court, 515 Anger, drawing depicting, 399 Atrophy Annular hymen, 230, 232, 241-242, 244 cerebral, 185

522 Index

optic, 209-210, 212 Basal ganglia Attachment computed tomography of, 166 emotional, 392 hypoxic injury and, 168 neglect and, 276 Basal skull fracture, Battle’s sign in, 10, 39 Attempted strangulation, 55 Basement Attitude, drawing expressing, 388 in police investigation, 374-382 Authentic voices, 479-480 kitchen in, 379-380 Automobile Bathroom child unattended in, 266 in police investigation, 354, 373 in domestic dispute case, 360 Bathtub in neglect case, 359 child unattended in, 268 Automobile accident, head injury in, 153 waste in, 270 Autopsy, social, 476 Bathtub burn, 122-123. See also Burn, immersion Avoiding abuse, drawing of, 394 Battery burn of genital area, 119 Avulsion, oral Battle’s sign accidental, 194 on ear, 39 in toddler, 9 of eye, 7 Axonal injury, diffuse, 169 BB gun, 339 Beating B with belt and fist, 30. See also Belt injury Babygram, 447 fatal head injury from, 139-140 Back with looped cord, 18 abrasion on, 26-27, 180, 305-306 multiple injuries from, 43 accidental burn on, 117 with paddle, 33 beating with radio antenna, 309 with radio antenna, 308-310 belt and fist injury to, 30 with several instruments, 29-30 bite mark on, 36, 49, 198, 201-203, 297-298, 306 with spoon, 336 bruise on, 90, 109, 305, 325 with stick, 35 in adolescent, 7 Bed, height of, 445 in cao gio, 57 Bedroom, in police investigation, 354-357, 366-373, 381- in neglect case, 346-348 382 cigarette burn of, 97 Belt injury, 24, 26-27 contact burn on, 103, 107 from buckle, 16 contusion on, 306 eschar from, 19 ecchymotic area on, 58, 81 to legs, 24-25, 345 extension cord injury of, 116 multiple, 30 immersion burn of, 78-79, 129 necrosis from, 38 injury to, 331, 344 pattern injury from, 342 kick injury to, 7 police investigation of, 335, 344-345 linear abrasions on, 19, 48 from strap, 16 loop marks on, 102, 116 to toddler, 24-25 macerated area on, 316-317 Binding injury marks on, in neglect case, 277, 346-348 to adolescent, 20 Mongolian spots on, 292-295 to toes of infant, 20 multiple injuries to, 48 Bite. See also Bite mark pattern bruises on, 74, 336 actual, 49 patterned injury on, 22, 26-27, 180 alleged, 48 pinch injuries on, 23 on buttocks, 14, 33, 299-300, 305-306 scalding injury to, 133 dog, 35 scarring on, 129 fatal, 197-198 Backyard in domestic dispute case, 383 on leg, 35 Bad black brain, 138 in fatal injury, 203 Balusters, fall between, 288-289 human, 36, 192, 198-203, 341 Band on arm, 198-200 of bruising, 33 on back, 201-203, of punctate lesions, 32 on foot, 199 Banding from elastic, 20 on leg, 32, 199

523 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

as patterned injury, 32, 35 Body integrity, drawing depicting fear for, 411 recognition of, 36, 191 Body mass index, 457, 459 recording of, 36, 192 Body slam, 5 referral of, 192 Body surface area, 68 reporting of, 36, 191 Bolus, alimentary, obstruction from, 323 Bite mark, 191-193, See also Bite Bone on abdomen, 297-298 fracture of. See Fracture on arm, 198-200, 203, 297-299, 307 radiological documentation of, 213-226, 447-449 armpit and, 341 Bone scan on back, 36, 198, 201-203, 298, 305-306 as documentation, 447 on buttocks, 14, 33, 203, 299-300, 305-306 in metaphyseal injury, 213 on calf, 306 of rib fracture, 222 on chest, 201, 307 Bone survey, long, 447 documentation of, 36, 192 Boyfriend, safety program for, 494-495 from dog, 35, 197-198 Boys, growth charts, 457-459 actual, 49 Brain alleged, 48 “bad black,” 138 in fatal injury, 203 swelling of, 141, 150, 163, 165, 176, 177 on foot, 199, 307 Brain damage, 137 from human, 36, 192, 198-203, 341 Brain death, 53, 207 on leg, 32, 199 Brain injury, 146-149, 169 medical examiner’s investigation of, 297-299 Brain tissue volume loss, 168 as patterned injury, 32, 35-36 Branding, 111,195 referral of, 192 Broom, beating with, 336 scab on, 200 fatal head injury from, 139-140 on shin, 307 Brow laceration, accidental, 63 on thigh, 299, 306 Bruise, 2-13 on toddler, 201-202, 297-299, 305-307 abdominal Bite mark scale ruler, 445 in infant, 13 Black eye photodocumentation of, 431 body slam causing, 5 in adolescent, 7 in toddler, 7 anterior to ear, 305 Bleeding on arm, 4, 17, 20, 303 intraperitoneal, 326 attributed to CPR, 177, 182 lichen sclerosis and, 233, 239 on back, 109, 325 mesenteric, 326 band of, 33 penile penetration causing, 258 beneath scalp, 146 retroperitoneal, 326 black eyes and, 4-7, 33, 63 into subarachnoid space, 138 on buttocks, 2, 4, 14, 17, 24, 46, 51, 90, 300, 305, 325, Bleeding disorder, bruising in, 4 336, 342 Blister, suck, 63 on cheek, 2, 47, 59, 305 Blood photodocumentation of, 418 in ear, 332 on chest, 321 from ruptured eardrum, 14, 46 in infant, 13 in scrotal injury, 65 on chin, 6, 44 in SIDS, 345 in death, 141-142, 146, 325 Blood vessel rupture, 181 on ear, 3, 39 Blue ribbon symbol, 476 in Ehlers-Danlos syndrome, 62 Bluish slate-colored lesion, 291-296 on eye, 47 Blunt trauma facial, 2-4, 6, 9-10, 24, 29, 48, 59, 343 abdominal, 52, 181, 326 in adolescent, 7 to chest, 326 in infant, 141 to head, 8 photodocumentation of, 418, 423-424, 434 to liver, 178 in toddler, 24, 29 lung injury from, 175 in fatal injury, 141-142, 146, 321, 324-325 Boa constrictor, cage, 381-382 forehead, 142 Board game, QuickThink, 497, 500 genital, 10, 51

524 Index

grab, 5, 183, 341 fireworks, 101 at hairline, 300 flame, 112, 342 on hand, 37, 303 folk medicine and, 58 on hip, 2 frostbite, 113 on infant, 12, 37, 340, 431 immersion, 70-82, 121-131. See also Burn injury, scald on knee, 4, 302-303 bathtub, 122-123 labial, 239 cooking temperatures and, 68 on leg, 17, 20, 51, 325, 335, 431 delay in care of, 121 in leukemia, 59 “doughnut”-shaped pattern of, 73, 126 multiple, 11, 52, 344 healing of, 125 in adolescent, 7 multiple, 73-82 in infant, 141, 321 perineal, 124 in preschool-aged child, 8, 300-303 police investigation of, 334-335, 343 in school-age child, 10 reported as chemical burn, 130-131 on neck, 51, 324, 330-332, 423 scarring from, 126, 128-129 in asphyxiation, 321 stocking-glove, 70-72, 124 in infant, 12 water lines shown by, 127 oral, 36, 195-196 multiple, 134 pattern of, 2-3 overview of, 67-69 patterned, 16-17, 196 photodocumentation of, 426, 428-430 of penis, 2, 259 scald, 83-89, 132-133 perianal, 259 abdominal, 83, 89 photodocumentation of, 418- 420, 422-426, 431, 434 of buttocks, 84, 87, 89 radio antenna causing, 308-310 of ear, 85 on scrotum, 2 of face, 83-84, 86, 132 in sexual assault, 313 of foot, 87-88, 135 on shin, 4, 307 genital, 86 on shoulder, 5, 51 of hand, 88 on sternum, 301 of lips, 86 in straddle injury, 258 multiple, 84 on thigh, 17, 301-302, 309-310 pattern with, 132-133 of toe, 51 photodocumentation of, 428 on trunk, 324 police investigation of, 334-335 Brunswick, Georgia, child advocacy center, 510 of thigh, 89 Bucket-handle fracture, 214, 218 space heater, 102-104 Building Success through Family Support, 481-482 accidental, 116 Bullying, campaign against, 476, 482-483, 497, 499 spill, 117-119 Bump on head, intracranial pressure and, 148 Butter, burn from, 83 Burn injury Buttocks accidental, 115-119 abrasion on, 305-306 vs. intentional, 68-69 beating with cue stick, 311 alcohol, 58 beating with radio antenna, 308-310 body surface area and, 68 bite mark on, 14, 33, 203, 297, 299-300, 305-306 to brand child, 111, 135 bruise on, 2, 51, 300, 305, 325, 336 butter, 83 in chronic illness, 4 to buttocks, 81, 84, 92, 97, 103-106, 111, 121 in hemophilia, 4 categories of, 67 multiple, 11 chemical, 80 in toddler, 2, 29 from fertilizer, 112 burn injury on of hand, 112 accidental, 116 immersion burn reported as, 130-131 from cigarette, 99 cigarette, 97-100, 280 circular, 109 contact. See Contact burn contact, 92, 97, 105, 108-109, 111, 116 curling iron, 92-97, 136 from curling iron, 92, 97, 136 in developmentally disabled child, 334 healed, 108-109, 111 documentation of, 446 immersion, 73, 76, 78, 81, 121-126. See also Burn, electrical, 113 immersion

525 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

from radiator, 103 Cervical spinal cord, epidural hemorrhage overlying, 172 scald, 84, 87, 89 Cervix from space heater, 104 duplication of, 235 diaper rash on, senna laxative causing, 114 in genital injury, 436 Henoch-Schönlein purpura and, 61 Chair, height of, 445 linear and looped marks on, 18 Chart Mongolian spots on, 38, 59 growth, 278, 282, 456-459 nevus on, 46 body mass index-for-age, 457, 459 pattern injury on, 14, 38, 342 head circumference-for-age, 457-458 pinch injury on, 17 length-for-age, 457 as target organ, 38, 46 stature-for-age, 456-458 C weight-for-age, 456-458 Calf weight-for-length, 456-458 bite mark on, 199, 306 weight-for-stature, 457, 459 burn injury on, 429 Cheek Callus, 433 belt injury of, 19 age of fracture and, 215, 221 branding burn on, 135, 195 on rib, 57, 176, 189 bruise on, 2, 47, 59, 196, 305 Calvaria, parietal, fracture of, 164 photodocumentation of, 418, 420 Camera ecchymosis of, 34 for documentation of abuse, 415-417, 443-444 slap injury of, 74 sexual, 451-452 Chemical burn, 80 recommendations for, 417 from fertilizer, 112 Cane, beating with, 312 of hand, 112 Cao gio, 57-58 immersion burn reported as, 130 Capillary hemangioma, 60 Chemical reaction, 119 Car Chemical restraint, 455 in domestic dispute case, 360 Chest in neglect case, 359 belt injury on, 16, 26 Care safety campaign, 476 Cardiopulmonary resuscitation, injuries attributed to, 177, bite mark on, 201, 307 182-183 blunt trauma to, 175, 326 Caregiver, police interrogation of, 330 bruise on Caries, rampant, 204 in infant, 13,321 Cascade, neuronal, 138 photodocumentation of, 420 Catch-up weight gain, 464 burn on Caudate head ganglion, 166, 168 accidental, 118-119 Cauliflower ear, 44-45 contact, 107, 109 Cavity, retinal schisis, 143 from curling iron, 93 Center, child advocacy, 505, 510-514 flame, 342 Centers for Disease Control and Prevention, growth charts, 456 immersion, 128 Cerebral anoxia, 210 from wringer, 106 Cerebral atrophy, 185 contusion on, 177, 307 Cerebral contusion, multiple, 183 healed scar on, 102, 128 Cerebral edema, 327 multiple injuries to, 48, 50 diffuse, 171 patterned injury on, 16 in ischemic injury, 138 squeezing injury of, 291-292 Cerebral hemisphere stomping injury of, 221 compression of, 164 diffuse cerebral edema of, 167, 171 Chest radiograph, 188-189 Cerebral hemorrhage, 52 as documentation, 447 Cerebral palsy, starvation of child with, 281-282, 316-318 for rib fracture, 188, 221, 433 Cerebral parenchyma herniation, 170 Child Abuse and Neglect, 480 Cerebrospinal fluid Child Abuse Prevention month, 478-479 hyperintense, 161 Child advocacy center, 510-514 in subarachnoid hemorrhage, 138 Child Maltreatment, 508

526 Index

Child protective services, 329 of head injury, 149 Children’s Hospital of San Diego conference, 506-507 of hyperdense foci, 169 Chin of liver laceration and hematoma, 222 abrasion on, 34, 64 of punching injury, 222 bruise on, 6, 44, 195 of ruptured pancreas, 223 contact burn to, 76 of subarachnoid hemorrhage, 162 fireworks burn of, 101 of subdural fluid collection, 159 Choking, 108 of subdural hematoma, 2, 144, 161, 167 Chronic fracture in infant, 219 of subdural hemorrhage, 435 Chronic illness, 4 of subgaleal hematoma, 148 Chronic metaphysitis, 214 Computer for photodocumentation, 417 Chronic subdural hematoma, 144 Computer graphics program, 2 Cigarette burn, 97-100, 134, 280 Concern for another, drawing expressing, 391 of arm, 98 Condyloma acuminata, 260-261 of back, 97 Condyloma lata, 262 of buttocks, 99 Conference on face, 100 APSAC, 506 on hand, 134 Children’s Hospital of San Diego, 506-507 multiple, 99-100 Crimes Against Children, 507 on scalp, 108 Huntsville, 507 Cigarette lighter, branding burn with, 135 ISPCAN, 506 Circle of Parents, 488-489 National Conference on Child Abuse and Neglect, 507 children’s program of, 495-496 on prevention, 484-485 Circular burn, 86, 109 on shaken baby syndrome, 508 Circumference, head, 456-458 Configuration of hymen, 230-232 increasing, 144 Congenital disease, 330-332 Circumferential hymen, 244 Conjunctival hemorrhage, 28, 34 Clavicular fracture, 188, 214, 304 Contact burn, 90-111 in infant, 217 accidental, 115-116, 135 Cleaning agent, 266 of abdomen, 92, 110 Cleft, 230, 249 accidental, 116 Closed head injury, 45, 52 of arm, 93-95, 98, 109-111 fatal, 146, 324, 327 accidental, 106, 115-116 Closet of back, 97, 102-104 in police investigation, 355-357, 369 branding, 111 Clue in drawing, 385 on buttocks, 92, 97, 99, 103-105, 109, 111, 136 Coffee table, 376-377 accidental, 116 Cognitive defense, 385-386 of chest, 93, 102, 109 Coining, 57-58 accidental, 106 Cold exposure, 147 to chin, 76, 101 Colleagues for Children, 483-484 from cigarette, 97-100, 108 Colon, fecal retention in, 319 from curling iron, 92-97, 136 Colposcopy to eye, 101 for documentation of sexual abuse, 451-452 from fireworks, 101 for photodocumentation, 415-416, 439-440 of foot, 95, 102, 135 recommendations for, 417 to genitals, 96 Coma, 6 of hand, 90-91, 110 Comb, pick, 13 accidental, 115-116 Communication, drawing as, 385-387 healing, 104, 109, 111, 136 Compression of cerebral hemisphere, 164 from iron, 90-91 Computed tomography on leg, 94 abdominal, 180, 185-186 multiple, 92, 105, 107-110 of basal ganglia, 166 of neck, 95 of brain tissue loss, 168 pattern injury from, 90, 92, 100, 107-109, 135 diffuse axonal injury and, 169 from radiator, 103 of diffuse cerebral edema, 171 of shoulder, 94, 102-108, 111, 115 of fall injury, 435 from space heater, 102, 104

527 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

on thigh, 101, 103, 135 Criminal investigation, 329-383. See also Investigation from wringer washer, 106 Crying program, 485-487 Contusion Cryomedics colposcope, 415-416 on back, 306 C-shaped mark, 14, 19 of buttocks, 179, 306 from wringer, 21 from belt, 24-25 CT myelogram, 189 cerebral, 183 Cupping, 58 on chest, 177, 307 Curling iron burn, 92-97, 136 to duodenum, 179 on abdomen, 92 on foot, 307 on arm, 93-95 on forehead, 146 of buttocks, 92, 97, 136 fracture, 164 on chest, 93 on hand, 303 of face, 95 hemorrhagic, 149 of foot, 95 interlabial, 235 on genital area, 92 of lip, 142 of leg, 94 to liver, 185 of neck, 95 lung, 175, 326 of penis, 96 mesenteric, 177 of scrotum, 96 multiple, 26-27, 177 on shoulder, 94 in occipital lobe, 149 on thigh, 92 to parietal lobe, 159 Curved mark, 19, 22, 298, 309 of penis, 53, 291 Cylindrical perianal condylomata, 261 scalp, 53, 150, 151 from straddle injury, 235 D subgaleal, 177, 183 Dads Make a Difference Too program, 494 on thigh, 306 Death. See also Fatal injury Cooking temperature, 68 asphyxia causing, 320-321 Cord, cervical spinal, 172 brain, 53 Cord injury, 26-27, 340 buried infant, 314-315 on back, 74, 116, 346-348 chest injury causing, 176-177 looped, 18-19, 38 from closed head injury, 324, 327 buttocks marks from, 38 drawing about, 386 restraint causing, 47 drug-related, 408 in strangulation, 55 from illness, 392 Corner fracture, 214, 220, 225-226 murder, 409-412 Corporal punishment from shaken baby syndrome, 412 buttocks as target in, 38 sudden, traumatic, 409-412 beating with radio antenna for, 308-310 duodenal injury and, 179 patterned injury in, 17 fall causing, 337 Corpus callosum, 169 forced feeding causing, 323 Cortical laminar necrosis, 166 head injury causing, 139-147 Courtroom, 515-516 impaction in, 319 demonstrations in, 465-467 liver laceration and, 178 Creatine phosphokinase in necrosis, 38 from malnutrition, 283-286 Crescentic hymen, 241 medical examiner’s investigation of, 287-327. See also in Tanner-stage-1 girl, 229 Medical examiner thickened, 243 multiple bruises in, 321 asymmetrical, 247 multiple injuries causing, 183 Crib oral injuries and, 322 burn injury and, 342 from pepper aspiration, 174 in neglect case, 357 police investigation of, from fall, 337-338 next to space heater, 271 severe neglect causing, 320 Cribriform hymen, 250-251 from soft tissue injury, 25, 27, 325 Crime scene reconstruction, 288-289 by starvation, 316-318 Crimes Against Children Conference, 507 traumatic asphyxia, 28 Criminal court, 515 Debris in room, environmental neglect and, 269

528 Index

Deck, height of, 446 living room, in, 361 Decubitus ulcer, 316 refrigerator in, 365, 380 DeKalb County, Georgia, child advocacy center, 510 stove in, 364, 379 Delayed care for immersion burn, 121 unsanitary conditions in, 364-374, 378-380 Demonstration, 465-467 weapons found in, 374, 380, 381 Dental neglect, 191, 265 Domestic violence, 6, 40, 42. See also Interpersonal violence; rampant caries as, 204 Violence Denticular hymen, 231 Dots on skin, 22 Developmental assessment in neglect, 455-456 “Doughnut”-shaped burn, 69, 73, 76 Developmentally disabled child Drainage in subdural hematoma, 138 burn injury in, 334 Drama troupe, HOPE!, 497 head circumference and, 144-145 Drawing, 385-414 rope injury in, 15 of aspects chart, 389-390 torture of, 29 client attitudes depicted in, 388 Developmentally disabled young adult, 16 of concern for another, 391 Diaper area, burn appearance of, 114 of death Dietary neglect, 275-286. See also Nutritional neglect caused by drug abuse, 408 Diffuse axonal injury, 138, 169 of parent, 392 Diffuse cerebral edema, 150, 171, 177 of sibling, 410, 412-413 Digital camera, 444 sudden traumatic, 409-412 Digital drawing of immersion burn, 428 digital, of immersion burn, 428 Digital image of exposure to sexual activity, 399 of oral injury, 192 of feelings of helplessness and worry, 390, 391 still image from video, 437 as foundation for storytelling, 394 Digital penetration of funeral, 413-414 alleged, 242 of illness and death, 392-393 old injury from, 264 of interpersonal violence, 386, 399-407 vaginal bleeding from, 257, 436 of murder, 409-410 Disabled child. See also Developmentally disabled child overview of, 385-387 pattern injury in, from rope, 15 of sexual abuse, 338, 394-398 torture of, 29 of shaken baby syndrome, 412-413 Disabled young adult, belt injury to, 16 of world events, 394 Discharge, vaginal, 230, 232, 236, 238, 246, 248 writing instead of, 388 Discoloration, skin, 295-296. See also Mongolian spot Drug paraphernalia, 271, 373, 377 Disposal of child, 147 Drugs Distended abdomen, 319 abuse related to, 408 Distinctive injury from beating, 311-312 accidental ingestion of, 268 Documentation death from, 408 of bite, 192-193 homicide related to, 411, 412 of neglect, 455-464 neglect related to, 270-271 normative charts in, 456-459 prescription, 377 overview of, 455-456 Duodenal hematoma, 187 use of charts in, 459-464 Duodenum video in, 455 contusion of, 8, 179 of sexual abuse, equipment for, 451-454 obstruction of, 187 Dog bite ruptured, 224 actual, 35, 49, 197, 198 DuPage County, Illinois, criminal court, 515, 516 alleged, 48 Duplication Doll in demonstration, 465, 467 of cervix, 235 Domestic dispute case, 360-383 of reproductive structures, 239 basement in, 375-378 vaginal, 235 bedroom in, 366, 370, 372, 381 Dura mater, 145, 158, 161 dangerous animals in, 382 drug paraphernalia in, 373, 377 E fecal matter on carpet in, 372 Ear food in, 363-365, 380 blood in, 14, 46-47, 332 kitchen in, 364 bruise anterior to, 305

529 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

bruise on, 39 Elijah’s story, 475 photodocumentation of, 420 Emerging Practices, 481 bruising at base of, 13 Emotion, drawing showing, 390-392, 395-397, 399, 411- cauliflower, 44-45 412, 414 ecchymosis behind, 33, 87 Emotional abuse erythema to, 22 documentation of, 455 hematoma of, 44-45 prevention programs for, 474 impact trauma to, 5, 40 Emotional attachment, drawing showing, 392 laceration on, 2 Encephalomalacia, 185 petechiae behind, 3 Enough advertisement, 473 scald burn of, 85, 87, 132 Entomology report, forensic, 314 as target organ, 39-40, 44-46 Environmental neglect, 269-273 Eardrum, ruptured, 46 Epidural hematoma blood from, 14 in alleged fall, 162 Ecchymosis unusual, 137 abdominal, 9 Epidural hemorrhage in accidental injury, 64 in fatal head injury, 152 on back, 48, 202 overlying cervical spinal cord, 172 behind ear, 33, 87 skull fracture with, 155 beyond impact area, 35 Epiphyseal injury, documentation of, 449 and bite marks, 202, 341 Epiphyseal separation, 214 on cheek, 34 Equipment for documentation of sexual abuse, 451-454 on chest, 50, 291-292 Erythema on chin, 34 on arm, 21 on face, 32-33, 35, 51 to helix of ear, 22 in folk medicine, 58 hot object causing, 22 on forehead, 64 of perianal area, 2 on hands, 61 photodocumentation of, 419 healing, 274 Eschar in Henoch-Schönlein purpura, 61 from belt injury, 19 lesions, 33 from wringer accident, 21 on neck, 204 Estonia, court in, 516 neglect and, 274 Estonia, child sexual abuse interview center in, 514 from paddle injury, 33 Estrogenization, 230 scrotal, 34, 65 intravaginal rugae and, 250 in sexual abuse, 204 normal, 249 on thigh, 34 Estrogenized hymen, 231 Edema in abused child, 245, 249 cerebral, 167, 171, 327 in normal findings, 242, 245-246 periorbital, 33 and projection, 236 pitting, of scalp, 5 Evidence collection, supplies for, 454 Ehlers-Danlos syndrome, 62 Evidence of choking, 108 Elastic, marks from Evidence worksheet for immersion burn, 446 on ankle, 20 Examination room in child advocacy center, 511 on arm, 20 Exposed wiring, 113, 375 as mimic of abuse, 60-61 Exposure Elbow cold, 147 abrasion on, 64 to environment, 314 accidental injury to, 64 to sexual activity, 399 fracture of Extension cord in infant, 217 back injury from, 116 supracondylar humeral, 216 electrical burn from, 194 Electrical burn loop marks from, 340 of foot, 113 External hymenal midline, 237 of hand, 113 Extremity. See also Arm; Leg oral, 194 documentation of injury of, 449 Electrical cord injury, 74 in starvation death, 316-317

530 Index

Eye Failure to thrive abrasion near, 34 documentation of, 456 accidental injury to, 63 length and weight charts for determining, 460 alleged fall injury to, 32-33 Fall black, 5, 7, 63 alleged bruise below, 4, 7, 42, 63 from crib, 32-33 bruise on, 7, 47, 63 down stairs, 34 conjunctival hemorrhage in, 84 epidural hematoma in, 162 corneal abrasion of, 46 crime scene reconstruction of, 288-289 examination of, 443 death of infant from, 337 in fatal head injury, 143 documentation of, 445-446 fireworks burn of, 101 injury not consistent with, 344 optic nerve injury to, 143, 163 photodocumentation of injury, 435 periorbital bruise and, 59 from window, 64 petechial hemorrhage beneath, 28 Family book, Woven Word, 497, 501 retinal hemorrhage in, 143, 211 Family Connections, 490-491 scleral hemorrhage of, 422 Fatal injury, 139-147. See also Death in shaken baby syndrome, 205-210, 212 from beating with broom, 139 hematoma in, 209 bite marks in, 203 macular hemorrhage in, 210 bruising in, 195 overview of, 205 chronic subdural hematoma and, 158 papilledema in, 210 epidural hemorrhage in, 152 retinal hemorrhage in, 210 eye in, 143 seizures and, 208 of head in unresponsive victim, 206-207 optic nerve injury with, 163 stick injury to, 35 parietal calvaria fracture in, 164 as target organ, 42-43, 46 pattern, 196-197 Eyelid scalp contusion in, 150, 151 ecchymotic area on, 32 in shaken baby syndrome, 176 laceration of, 19 skull fracture in, 157 petechial hemorrhages on, 28 multiple, 154-155 occult, 151 F from stomping, 221, 224 Face from suffocation, 141, 210 accidental burn of, 117 Father, prevention programs for, 493-494 branding burn on, 195 Fathers and Children Together program, 493 bruise on, 2-4, 6, 51, 52, 196, 321, 343 Fear, drawing depicting, 396, 411, 412 in adolescent, 7 Fecal matter on carpet, in domestic dispute case, 372 in fatal head trauma, 139 Fecal retention, 319 in toddler, 2, 3, 9, 10, 24, 29, 59 Feeding burn on inadequate, 463 cigarette, 100 weight-for-age and, 463 contact, 108, 109 Feelings, drawings to express, 388, 390, 397, 407 curling iron, 95 Femoral fracture fireworks, 101 corner, 225 scald, 84, 86, 132 documentation of, 449 ecchymosis on, 33, 35 force used in, 214 multiple injuries to, 52 photodocumentation of, 432 petechiae on, 3, 29 spiral, 216 photodocumentation of injury to, 418, 420, 423, 424, Fight Crime campaign, 477 434 Film photography of oral injury, 192. See also pick comb injury to, 13 Photodocumentation slap mark on, 14 Filter, ultraviolet light, for Mongolian spots, 293-296 strike marks on, 349 Fimbriated hymen, 231 as target organ, 43, 44 Finger, fertilizer burn on, 112 Factors for Effective Prevention Programs, 482 Finger imprint, 5, 14 Failed midline fusion, 234, 237 Fire, flame burns from, 342

531 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

Fireworks burn, 101 greenstick, 304 First Steps, 485, 492 healing, 54 Fissure of humerus, 188 anal, 2 multiple, 217, 220, 221, 304, 447 rectal, 49 parietal bone, 153, 156 Fist injury cerebral parenchyma herniated through, 170 to adolescent, 7 of parietal calvaria, 164 multiple, 30 photodocumentation of, 432-433 Flame burn, 112 of posterior fossa, 152 Flat warts, 262 radiographic documentation of, 447-449 Flexion fracture, 448 of radius, 186, 220, 304, 433 Fluid, cerebrospinal rib. See Rib fracture hyperintense, 160-161 skull. See Skull fracture in subarachnoid hemorrhage, 138 spinal radiographs showing, 448-449 Fluid collection, subdural, 159 ulnar, 186, 220, 304, 433 Folk medicine, 57-58 Frenulum Food laceration of, 24 in domestic dispute case, 363-365, 380 torn, 44, 50 nutritional neglect and, 275-286. See also Nutritional in fatal injury, 141, 322 neglect Friability, anal, 435 Foot Frog-leg position, 228-229 abscess on, 320 Frontal white matter, hyperdensity in, 169 bite mark on, 199 Frontoparietal scalp injury, 53 burn on Frostbite, 113 curling iron, 95 Full thickness immersion burn, 121 electrical, 113 Fundus copy, in shaken baby syndrome, 206-212 from hot stove, 135 Funeral, drawing about, 413-414 immersion, 75, 122-124, 127, 128, 130, 131 Furnace grid, burn from, 116 scald, 87, 88 Fusion space heater, 102 failed midline, 234, 237 stocking-glove pattern of, 71, 124 labial, 234, 237 contusion on, 307 frostbite of, 113 G Force in fracture, 214 Ganglia, basal, 166, 168 femoral, 214 Garbage in home, 272 Forced feeding, death from, 323 Garroting injury, 15 Forearm Gas line, 379 bruise on, 303 Gas stove, 379 burn on General prevention messages, 475 contact, 110 Genital area curling iron, 93, 94 bruise on, 2, 10, 51 self-inflicted scratch to, 312 burn on Forehead contact, 92, 96 bruise on, 2, 64, 195 fireworks, 101 in fatal injury, 142 immersion, 121-122, 124 burn on, 117 scald, 86 contusion on, 146 chemical reaction on, 119 midline impact, 63 laceration of, 290 Foreign body, 236, 238 pattern injury on, 340 Forensic entomology report, 314 Genital bleeding, 255 Foreskin, prepuce, 34 Genital injury. See also Genital area Fork, contact burn from, 107 from beating with cue stick, 311 Fossa, popliteal, 4 photodocumentation of, 436, 438, 441 Fracture Genitalia. See also Genital area clavicular, 188 bruise on, 2, 51 demonstration of, 465-466 curling iron burns on, 92, 96 documentation of, 447-449 Georgia Fathers program, 494

532 Index

Gingiva, 28 Head circumference-for-age chart, 458 Girls growth chart, 457-459 in short stature, 461 Grab mark, 5, 341, 349 Head injury, 137-172. See also Epidural hemorrhage; photodocumentation of, 425 Subarachnoid hemorrhage; Subdural hematoma; Grand mal seizure, 2 Subgaleal hemorrhage Grandfather as abuser, drawing of, 395 abrasion, 32 Graphics program, 2 in automobile accident, 153 Greenstick fracture, 304 to basal ganglia, 166, 168 Grid, hot, 22 bruise, 195, 321 Groin area, immersion burn of, 75, 121-122, 124 burn, 117 Grossman Burn Center Study, 68 cephalhematoma, 148, 178 Group support, Parents Anonymous, 488-489 closed, 45, 52, 146, 324, 327 Growth coma caused by, 6, 52, 53 documentation of, 456 blunt trauma causing, 8 weight gain and, 464 corpus callosum hemorrhage from, 169 Guidelines for finding biter’s age, 192 death from, 40, 139, 141-143, 146-147, 150-152, 154- Guilt, internalization of, 397 155, 157-158, 163-165, 177, 324, 327 Gun, 268 ecchymosis, 64 Gunfight, drawing of, 402 epidural hematoma, 137, 162 Gunshot wound, 324 hypoxic, 138, 166, 168 Gyrus, fracture of, 164 imaging of, 140, 144-145, 148-149, 151, 153, 156, 159-162, 166-172, 185-189, 447 H increased intracranial pressure and, 148, 152, 327 Hair skull fracture, 140, 151-157, 164, 170 binding with, 20 from slamming, 6, 149, 170 pulling of, 21 Headache, thunderclap, 138 Hairbrush injury Healed burn on buttocks, 111 to hand, 41 Healed burn on chest, 102 patterned, 22 Healed fracture of radius and ulna, 220 Hairline, bruise at, 300 Healing Hallway in domestic dispute case, 374 age of fracture and, 215 Hana Like Home Visitor program, 489 of curling iron burn, 136 Hand of fracture, 54 bruise caused by, 2, 5, 29, 55, 422, 424 of frenulum laceration, 24 bruise on, 303 of immersion burn, 125 in newborn, 37 of transected hymen, 253 burn on Healthy Families Georgia, 490 accidental, 115, 119 Heater, next to crib, 271 chemical, 112 Heating vent, burn from, 22 contact, 81, 90, 103, 116, 134 Height electrical, 113 documentation of, 445 flame, 112 in normative charts, 456-457 immersion, 82, 119, 128 of object, 445-446 scald, 88, 110 Helix of ear, 5, 22 stocking-glove pattern of, 70, 72 Helplessness, drawing expressing, 390-391 in drawing, 395, 411, 412 Helpline, 487, 496-497 ecchymosis on, 274, 310 Hemangioma, 240 Henoch-Schönlein purpura and, 61 capillary, 60 loop mark on, 18 Hematoma radio antenna injury to, 310 anal, accidental, 260 reticuloendotheliosis of, 37 duodenal, 187 as target organ, 37, 41 of ear, 44, 45 Hand mark of liver, 222 on infant, 14 in sexual abuse, 253 on toddler, 29 in shaken baby syndrome, 209 Handle, broom, beating with, 336 subdural. See Subdural hematoma Head circumference, increasing, 144 subgaleal, 149, 151, 162

533 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

from shaking, 148 Hostility, drawing depicting, 399 from slamming, 149 Hot butter burn, 83 Hemisphere, cerebral Hot object, patterned injury from, 22 compression of, 164 Hot water burn. See Burn, immersion diffuse edema of, 167, 171 Hot water heater, 378 Hemophilia, bruising in, 4 How to Help Kids Stay Safe, 494 Hemorrhage How You Can Take Part in Prevention Efforts, 479 cephalhematoma, 137, 148, 172 Human bite, 36. See also Bite mark cerebral, 52 Human papillomavirus, 262 conjunctival, 34 Humeral fracture, supracondylar, 216 epidural, 172 Humerus in fatal head injury, 152 fracture of, 188, 216 skull fracture with, 155, 162 metaphyseal injury of, 225 imaging of, 145, 161-162, 169, 171, 226, 435 Huntsville Conference, 507 in kidney, 184 Hymen macular, 210 annular, 229, 230, 232, 241, 244 of optic nerve sheath, 143, 163 intact, 242 from periosteal stripping, 215, 226 circumferential, 244 petechial configurations of, 230-232 in asphyxiation, 320, 321 crescentic, 241 in attempted strangulation, 55 cribriform, 250, 251 retinal, 141, 143, 163, 205-212 denticular, 231 scleral, 422 estrogenized, 231, 236, 245, 246 in splenium of corpus callosum, 169 in abused child, 249 subarachnoid, 138, 162 fimbriated, 231 in parasagittal region, 163 imperforate, 233 subdural hemorrhage with, 165 rectal fissures and, 49 subconjunctival, 3, 59, 321 intact, 236, 242, 247 subdural, 171, 435 integrity of, 246 in fatal injury, 57, 141, 142, 147, 150, 163 laceration of, 238, 256-258, 259, 436 subarachnoid hemorrhage with, 165 normal, 248 subgaleal, 137 with penetration, 242, 252 in fatal injury, 5, 142, 147 redundant, 229-230 skull fracture with, 154-155, 157 septate, 232 submucosal, 438 thickened, 230, 243 in temporalis muscle, 164 transected, healed, 253, 264 Hemorrhagic herpes, 261 Hymenal Hemosiderin staining in dura mater, 145, 161 laceration of, 258 Henoch-Schönlein purpura, 61 superficial, 256 Herniation, cerebral parenchyma, 170 Hymenal midline, external, 237 Herpes Hymenal mound, 246, 249 hemorrhagic, 261 Hymenal pit, 251 perianal, 260 Hymenal projection, 230, 236, 245, 248 Hide and Seek advertisement, 473 Hymenal rim, posterior, 238, 248 High chair, 380 Hymenal tag, 248 High-velocity impact injury, 153, 336 Hymenal tear, 253 Hip Hyperdense interhemispheric subdural hematoma, 167 belt and fist injury to, 30 Hyperdensity in frontal white matter, 169 bruises on, 2 Hyperextension injury, epidural hemorrhage and, 172 loop mark on, 46 Hyperintense cerebrospinal fluid, 159 Home Alone program, 495 Hyperintense subdural hematoma, 160 Home investigation Hyperintensity in domestic dispute case, 360-383 in basal ganglia, 166 in neglect case, 350-359 in hypoxic injury, 168 Homicide. See Fatal injury Hypervigilance, drawing showing HOPE! Drama Troupe, 497, 500 after murder of brother, 410 Hopelessness, drawing expressing, 390 after sexual abuse, 396

534 Index

Hypoxic ischemic injury, 138 head circumference-for-age chart for, 458 head injury to, 148-149, 153, 161, 176 I imperforate hymen in, 233 Illness, drawing depicting, 392 increased intracranial pressure in, 148 Imaging. See Computed tomography; Radiology interhemispheric subdural hematoma in, 159 Imaging software for oral injury, 192 labial fusion in, 237 Immersion burn, 70-82, 121-131. See also Burn, immersion laceration in Impaction, intestinal, 319 liver, 178, 222 Imperforate hymen, 233 parietal lobe in, 170 rectal fissures and, 52 length of, 456 In Loving Hands Kids Blossom, 478-479 length-for-age chart for, 457 Inadequate feeding, 464 lump over parietal bone in, 172 Index, body mass, 457, 459 lung contusion in, 175, 326 Infant. See also Shaken baby syndrome medical neglect of, 121 anal tear in, 253 multiple injuries to, 50, 53, 423 asphyxiation of, 321 nutritional neglect of, 275-276, 279 in automobile accident, 153 papilledema in, 210 basal ganglia of, 166 pepper aspiration in, 174 binding injury to, 20 pinch marks on, 23 bite marks on, 198 radiograph of, 447 brain injury in, 176 scalp contusion in, 151 bruise on scleral hemorrhage in, 422 on abdomen, 13, 431 shaken, 148 on back, 425 SIDS death of, 345 of chin, 6 slap mark on, 14 on face, 13, 340, 423 soft tissue injury of, 325 on hand, 37 squeezing injury of, 291-292 of leg, 422, 431 subarachnoid hemorrhage in, 138, 162, 165 on neck, 12 subdural hemorrhage in, 165 buried, 314-315 Infection burn injury to from immersion burn, 121, 131 contact, 22, 430 from looped cord injury, 18 from firework, 101 oral, 204 from flame, 342 perianal streptococcal, 262 immersion, 121, 122 sexually transmitted. See Sexually transmitted disease scald, 87, 89, 132-133, 428 wound, 280 stocking-glove pattern of, 71 Ingestion, risk of, 266, 268 death of, drawing depicting, 412-413 Institutional safety neglect, 52 diffuse cerebral edema in, 171 Intact hymen, 236, 242 epidural hematoma in, 162 Intact posterior rim, 247 fall by, 445 Integration of abuse memories, 400-401 fatal beating of, 139-140 Intentional injury, 214 fatal head injury in, 139-143, 151-152, 324 target organs in, 37-38 eye injury in, 143 Intercourse fracture in anal, 36, 38, 244-245, 252, 259 bucket-handle, 218 hymen resulting from chronic, 219 interrupted, 263 femur, 432 laceration of, 256-257 humerus, 188 normal intact, 242 multiple, 217, 304 separation of, 242 parietal bone, 156 transection of, 263 rib, 175, 176, 185, 220, 325 labial, 258 skull, 156 vaginal, 252, 263 genital injury in, 436 vaginal bleeding and, 258 grab marks on, 425 Interhemispheric subdural hematoma, 159 hand injury of, 41 hyperdense, 167 hand mark on, 14 Interlabial contusion from straddle injury, 235

535 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

Internalization of emotion, drawing showing, 397 International Journal of Child Abuse & Neglect, 510 J Jejunum, transected, 180 International Society for Prevention of Child Abuse and J-shaped mark, 19 Neglect, 504 Juvenile court, 515 conference, 506 publications, 510 Interpersonal violence, drawing of, 386, 399-407 K Kerosene can, 269 anger, hostility, and aggression, 399 Kick injury, 7 before and after conscious memory of, 400-401 Kidney hemorrhage, 184 killing abuser, 403-407 Killing of abuser, drawings of, 403-407 witness to gunfight, 402 Kitchen Intertrochanteric fracture, 432 in domestic dispute case, 364, 379-380 Interview room of child advocacy center, 512 in neglect case, 353 Intestinal impaction, 319 Knee Intracranial perfusion, lack of, 171 bruise on, 4, 302, 303 Intraperitoneal air, 319 bucket-handle fracture of, 218 Intraperitoneal bleeding, 326 burn on, 121, 334 Intravaginal ridge, 243, 246 nonabusive injuries to, 293 Intravaginal rugae, 248 Knee-chest position, 228 estrogenization and, 250 normal findings in, 247 Investigation, 329-383 Knife, 267 of accidental versus inflicted injury, 340-345 bite marks, 341 bruise on face, 340, 343 L ecchymosis, 341 Labial bruising, 239, 258 flame burns, 342 Labial fusion, 234, 237 grab bruises, 341 Labial separation, 228 multiple bruises, 344 Labial traction, 228 pattern bruises, 340, 342, 344, 345 Laceration scald burn, 343 accidental, 66 sudden infant death syndrome, 345 anal, 36, 256 of beating, 336 anal intercourse causing, 36 of burn, 334-335 from belt, 19 of child of short stature, 330-332 brow, 63 in domestic dispute case, 360-383. See also Domestic of duodenum, 179 dispute case of frenulum, 24 of fall landing on child, 337-338 hymenal, 238, 256-258, 436 forensic entomology, 314 liver, 13, 178, 182, 184, 185, 222 interrogation of caregivers in, 330 looped, 18 by medical examiner, 287-327. See also Medical of mouth, 90 examiner of nose, 22 overview of, 329-330 of parietal lobe, 170 of report of maltreatment, 330-338 penetration causing, 256-259 of scald injury, 334-335, 343 perianal, 257, 259 of scene, 346-383 in sexual abuse, 254 in neglect case, 346-359 from tooth, 43 of suspicious bruise, 333 vaginal, 257 Investigational tools in documentation, 444-447 Ladder, 267 Iowa Fathers program, 494 Laminar necrosis, cortical, 166 Iowa First Steps, 492 Lash marks, 427 Iowa Stork’s Nest program, 492 Lashing, 29 Iron, burn from Laxative, burn appearance from, 114 on hand, 90, 91 Leadership photodocumentation of, 429 Parents Anonymous, 480, 481 Ischemic injury, hypoxic, 138, 166 shared, in prevention, 485 ISPCAN, 504 Leg belt injury to, 16, 24, 30, 335, 345

536 Index

bite mark on, 32, 199 laceration of, 13, 178, 182, 184, 185, 222 bruise on, 4, 44, 51, 60, 325, 422 Living room photodocumentation of, 431 in domestic dispute case, 361, 376 burn of in neglect case, 351 contact, 92, 107 Logo curling iron, 92, 94 APSAC, 503 flame, 112, 342 from curling iron, 92 from hot stove, 135 ISPCAN, 504 immersion, 73-77, 79-80, 121-123, 127, 130-131, 343 NCA, 505 scald, 117, 334-335 PCA America, 505 stocking-glove pattern of, 71 Long bone survey, 447 documentation of injury to, 449 Loop mark dog bites on, 35 from cord, 18, 31, 116, 340 in Ehlers-Danlos syndrome, 62 on face, 43 Henoch-Schönlein purpura and, 61 on hand, 18 pattern injury on, 37, 340 multiple, 26, 35, 46 petechiae on, 32 old, 29, 102 pinch injury on, 17 scarred, 37 Leisegang camera, 415 on thigh, 24, 31 Leisegang colposcope, 415, 416 Lucid interval theory, 137 Length-for-age chart, 457 Lumbar spine, radiographs of, 448, 449 in failure to thrive, 460 Lump over parietal bone, 172 in feeding difficulty, 463 Lung injury in inadequate feeding, 464 from blunt trauma, 175 in short stature, 461, 462 contusion, 175, 326 Let’s Explore Your Empathy Eye, 483 from pepper, 174 Leukemia, bruising in, 59 Lichen planus, penile, 262 M Lichen sclerosis, 233 Maceration, 316-318 bleeding with, 239 Macro photography, 426 Lichenified mark, 17 Macular hemorrhage, 210 Lighter burn, 76, 100, 135, 430 Macule, 293-296. See also Mongolian spot Line, midline white, 245 Magnification in photodocumentation, 426 Linear mark Malnutrition, 8, 275-286 on abdomen, 31 Mandated Reporters Guide, 483, 484 on back, 19, 22, 29, 30, 48 Manipulation of photographs, 444 from belt, 16, 30 Mark, loop. See Loop mark on chest, 48 Mask, 393 from hand, 29 Mason City, Iowa, city court, 515 on hand, 41 Mattress, damaged, 273 from hot grid, 22 Medical examiner, 287-327 in many directions, 19, 22, 29 crime scene reconstruction by, 288-289 on neck, 12, 15, 55-56 death investigated by scarred, 37 abdominal trauma in, 326 on thigh, 29, 31, 35 from asphyxia, 320-321 Linear petechiae, 29 buried infant, 314-315 Link, The, 510 chest trauma in, 326 Lip closed head injury in, 324, 327 accidental injury to, 64 by forced feeding, 323 bruise on, 195, 196 by gunshot wound, 324 contusion of, 142 from intestinal impaction, 319 laceration of, 39, 90 multiple bruises in, 321 scald burn of, 86 oral injuries in, 322 as target, 40, 42 rib fracture in, 325 Liquid acid burn, 112 from severe neglect, 320 Liver soft tissue injury, 325 blunt trauma to, 178 from starvation, 316-318

537 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

of teenager, 323 on buttocks, 38, 59 role of, 287 on leg, 23 suspicious injuries examined by as skin discoloration, 295-296 abused siblings, 305-307 Monilial rash, neglect of, 274 beating with cane, 312 Monitor, in examination room, 454 beating with cue stick, 311 Mound, hymenal, 243, 246 beating with radio antenna, 308-310 cleft with, 249 beating with switch, 312 Mouth. See also Oral injury bite marks, 297-299 beating injury to, 42 multiple fractures, 304 bruise of, in fatal injury, 141 nonabusive skin lesions, 293-295 laceration of, 90 ongoing maltreatment, 300-303 suffocation injury to, 141 penile laceration, 290-291 as target organ, 39, 40, 42-44 self-inflicted scratches, 312 Multiple fracture, 304 sexual assault, 313 of different ages, 220, 221 skin discoloration, 295-296 Multiple injuries, 47-54 squeezing, 291-292 attributed to CPR, 182 Medical neglect, 265, 274 from beating, 43 documentation of, 455 from belt, 24, 26 of burn, 121, 131 bruising in, 5, 8, 10-11 Medication burn, 134 accidental ingestion of, 268 on chest, 50 prescription, in domestic dispute case, 377 by cigarette burns, 99, 100 prescription, in neglect case, 352 contact burns, 105, 107-110 Meeting rooms of child advocacy center, 513 contusion in, 26, 27 Megacolon, 319 in death, 321 Memory fatal, 141 of abuse, drawings showing, 400-401 immersion burn, 73-82 of deceased, 409 with insufficient history, 183-184 prenatal, drawings of, 392 loop and linear marks, 35 Mesenteric bleeding, 326 photodocumentation of, 423 Mesenteric contusion, 177 police investigation of, 344 Metaphyseal injury scald burns, 84 in bucket-handle fracture, 218 sexual abuse, 203 documentation of, 449 in siblings, 305-307 of proximal humerus, 225 skull fracture, 140, 154-155 Metaphysitis Murder, drawing about, 409-412 chronic, 214 Muscle, temporalis, hemorrhage in, 164 traumatic, 214, 225, 226 Muscle trauma, 38 Midline, external hymenal, 237 Myelogram, CT, 189 Midline fusion failed, 234, 237 N Midline white line, 245 Nail, marks from, 22 Midshaft greenstick fracture, 304 National Center on Shaken Baby Syndrome, 486-487, 505 Mimic of abuse National Children’s Alliance, 505 capillary hemangioma as, 60 National Clearinghouse on Child Abuse and Neglect Ehlers-Danlos syndrome as, 62 Information, 503 elastic-related marks as, 60 National Conference on Child Abuse and Neglect, 507 Henoch-Schönlein purpura as, 61 Natural death, 330-332 leukemia-related bruising as, 59 Near strangulation, 56 Mongolian spot as, 59 Neck suck blister as, 63 accidental injury to, 56, 64 Missouri antibullying campaign, 476 spill burn on, 118 Missouri car safety campaign, 476 bruise on, 12, 51, 195, 324 Molluscum contagiosum, 263 photodocumentation of, 423 Mongolian spot curling iron burn of, 95 on back, 294 evidence of choking on, 108

538 Index

garroting injury to, 15 Occult skull fracture, 151 linear marks on, 12, 15, 55, 56 Olympus colposcope, 416 in neglect case, 348 Ongoing maltreatment, 300-303 photodocumentation of lesion on, 418 Opening, large urethral, 241 petechiae on, 28, 320 Ophthalmology in shaken baby syndrome, 205-210, 212 suction mark on, 204 hematoma and, 209 Necrosis macular hemorrhage and, 210 belt injury causing, 38 overview of, 205 cortical laminar, 166 retinal hemorrhage and, 210 Need to Talk Helpline, 496-497 seizure and, 208 Neglect, 265-286 Ophthalmoscopic examination, 205, 443 death caused by, 316-318, 320 Optic atrophy, 209 dental, 191 Optic nerve injury, 143 environmental, 269-273 in shaken baby syndrome, 206-207, 209-212 immersion burn and, 121 skull fracture with, 163 institutional safety, 55 Ora serrata, 143 lack of attachment and, 276 Oral injury, 191-204. See also Mouth medical, 274 avulsion nutritional, 273, 275-286. See also Nutritional neglect accidental, 194 overview of, 265 inflicted, 194 police investigation of, 346-359 from beating, 42, 197 of automobile, 359 bite. See Bite of home, 350-358 bruise, 195-196 pattern injury in, 346-349 burn prevention programs for, 474 branding, 195 safety, 21, 35 electrical, 194 supervisory, 266-268 in death, 322 Nerve, optic. See Optic nerve injury dental neglect causing, 204 Neuronal cascade, 138 from gunshot, 324 Nevus, on buttocks, 46 overview of, 191-193 New Hope for Preventing Child Abuse and Neglect, 477 pattern, 196-197 New parent materials, 485-489 Organization, courtroom, 516 Newborn, bruises on hands of, 37 Nikon camera, for photodocumentation, 415-416 P Nonabusive skin lesion, Mongolian spot as, 293-295 Paddle injury, 26, 38 on buttocks, 38, 59 delayed ecchymosis from, 32-33 photographic examination of, 293-295 Palpebral conjunctiva, 320 Normal examination Pancreas, ruptured, 223 after sexual abuse, 243, 245 Pancreatic pseudocyst, 186, 223 Normative chart, 456-464 Papilledema in suffocation, 210 Nose, laceration of, 22 Papillomavirus infection, 262 Nuclear medicine scan. See Bone scan Paraphernalia Nurturing environments campaign, 477 drug, 271, 373, 377 Nutritional neglect, 265, 273, 275-286 ritualistic, 381 of infant, 275-276, 279 Parasagittal region, 163 of preschool-age child, 280 Parenchyma herniation, cerebral, 170 of school-aged child, 280-282 Parent, prevention programs for, 485-489 of toddler, 277-278, 283-286 Parent training, 481 Nutritional rehabilitation, 275 Parents Anonymous, 488-489 children’s program of, 495 O leadership of, 480 Observation room of child advocacy center, 512 Parietal bone, lump over, 172 Observing and Learning from Your Students’ Behavior, 483 Parietal bone fracture Obstruction in automobile accident, 153 from alimentary bolus, 323 cerebral parenchyma herniated through, 170 duodenal, 187 intentional, 156 Occipital lobe contusion, 149 Parietal calvaria, fracture of, 164

539 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

Parietal lobe contusion of, 53 contusion to, 159 drawing of, 338 laceration of, 170 laceration of, 290-291 Parietal subdural hematoma, 435 lichen planus of, 262 Partial thickness burn pinch injury to, 33 immersion, 121-124, 127, 131 straddle injury of, 65 from stove, 135 swollen prepuce of, 34 Patterned injury, 14-37 Pepper, lung injury from, 174 abrasion causing, 48 Perfusion, intracranial, lack of, 171 anal, 36 Perianal bruising, 259 on back, 26, 29-30, 180, 346-347 Perianal condyloma, 261 banding, 20 Perianal herpes, 260 from belt, 16, 19, 24-25, 30, 335, 342, 344-345 Perianal laceration, 257, 259 bite causing, 32-33, 35, 36, 197-202. See also Bite mark Perianal streptococcal infection, 262 from broom, 139, 336 Perianal vitiligo, 240 bruises as, 29, 183 Perineal injury in sexual assault, 313 burns as Perineum, immersion burn of, 122-123 branding, 111, 195 Periorbital bruise in leukemia, 59 chemical, 112 Periorbital burn from fireworks, 101 from cigarette, 98-100 Periorbital edema, 33 from curling iron, 136 Periosteal stripping, 215 “doughnut”-shaped, 73, 76, 126 in femur, 226 from heater, 102-104, 116 Peritonitis, 180 from hot object, 22 Personal safety program, 495-496 immersion, 126-127 Personality, aspects chart of, 389-390 from iron, 90-91 Pet carrier, 369 from lighter, 100, 135 Petechiae scalding, 132-133 on face, 3, 29 from spill, 133, 428 in infant, 23 stocking-glove, 70-72, 124 on leg, 32 from stove, 135 from pinch, 23 on buttocks, 16, 29, 126, 342 Petechial hemorrhage from fist, 30 in asphyxiation, 320-321 garroting causing, 15 in attempted strangulation, 55 hair pulling as, 21 Photodocumentation, 415-442 from hand, 2, 29 of bruise, 418-420, 422-425, 431 loop mark, 18, 24, 29, 31, 35, 37, 74, 116, 340 of burn injury, 428-430 on neck, 15 colposcopic, 439-440 nutritional neglect with, 277 as documentation of abuse, 443-444 oral, 196-197 equipment for, 415-417, 451-452 paddle injury causing, 33 of facial injury, 418, 420, 434 pinching causing, 23 of fall injury, 435 police investigation of, 335-336, 340, 342-347 of fracture, 432, 433 from spoon, 336 of genital injury, 436, 438, 441 wringer causing, 21 of grab marks, 425 PCA America, 505 of lash marks, 427 Penetration magnification in, 426 acute, 256 of Mongolian spots, 293-296 bleeding after, 258 of multiple injuries, 423 digital, 264 of oral injury, 192 laceration after, 257 overview of, 415-417 normal findings with, 252 of scleral hemorrhage, 422 old injury from, 263 setup for, 438 perianal laceration from, 259 of sexual abuse, 451-454 Penis video, 437, 440, 455 bruise on, 2, 259 of wrist splint bruise, 431 burn on, 96, 259 Physical abuse

540 Index

burns in, 134 immersion burn of documentation of, 443-449 “doughnut” pattern of, 126 cameras for, 443-444 healing of, 125 eye examination for, 443 scarring of, 126 investigative tools for, 444-447 labial fusion in, 234 radiographic, 447-449 large urethral opening in, 241 immersion burn as, 122-123, 125, 131 lichen sclerosis in, 233 prevention programs for, 474 loop and linear marks on, 29 Pick comb injury, 13 Mongolian spots on, 295-296 Pinch injury multiple bruises on, 8, 10, 52 to infant, 23 multiple injuries of, 49, 52 multiple, 17, 23 nonabusive skin lesions on, 293-295 to penis, 33, 259 nutritional neglect of, 280 Pinworm, 240 ongoing maltreatment of, 300-303 Pit, hymenal, 251 patterned injury to, 22 Pitting edema of scalp, 5 perianal laceration in, 257, 258 Plastic container, 270, 358 skin discoloration of, 295-296 Platform, advocacy, 479 space heater burn of, 103 Platform for Children and Youth, The, 479 straddle injury in, 235 Pneumoperitoneum, 186 urethral support structures in, 247 from ruptured duodenum, 224 vaginal laceration in, 257 Police investigation, 329-383. See also Investigation Prescription medication, 377 Political will for prevention, 476-477 Pressure sore, 316-318 Pooling, anal, 244 Pretzel, in demonstration of fracture, 465, 466 Popliteal area, immersion burn of, 75 Prevent Child Abuse America, 505 Popliteal fossa, bruise on, 4 conferences of, 484-485 Pornography, 339 prevention strategies of, 472 Portable stove, 269 publications of, 475, 478-479, 482-483, 486, 488, 494, Poster in demonstration, 465 497, 499 Posterior fossa, fracture of, 152 Prevent Child Abuse Georgia, 472-474 Posterior hymenal mound, cleft with, 249 annual report of, 478-479 Posterior hymenal rim conference brochure of, 484 intact, 247 crying program of, 485-486 normal, 238, 248 First Steps Program, 485 Postmortem. See also Medical examiner Helpline, 496 of buried infant, 314-315 Prevent Child Abuse Helpline, 487 examination, 314-327 Prevent Child Abuse Indiana, 495 rectal image from, 439 Prevent Child Abuse Louisiana, 479-480 Power of Prevention, 484 Prevent Child Abuse North Carolina, 472 Precocious puberty, 249 Prevention program, 469-502 Prenatal memory, drawings of, 392 advocacy, 476-480 Prepubertal child, vaginal discharge in, 232 advocacy summits, 479 Prepuce, swollen, 31 authentic voices, 479-480 Preschool-aged child building public and political will, 476-477 abdominal injuries in, 186 Child Abuse Prevention month, 478 anal intercourse with, 36 fight crime, 477 anal tag in, 242 nurturing environments, 477 bleeding after penetration in, 258 Parents Anonymous leadership, 480 bruises on buttocks of, 336 Platform for Children and Youth, The, 479 cribriform hymen in, 250, 251 prioritizing, 478-479 external hymenal midline in, 237 challenges in delivery of, 469-470 facial bruising in, 424 for children, 495-496 failed midline fusion in, 234 Aid to Children of Imprisoned Mothers, 496 fatal head injury of, 150 Circle of Parents, 495-496 hemorrhagic herpes in, 261 helpline, 496-497 hymenal mound in, 246, 249 Parents Anonymous, 495-496 hymenal tag in, 248 Project Healthy Grandparents, 496

541 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

for high-risk parents, 489-494 Prevent Child Abuse Louisiana, 480 Aid to Children of Imprisoned Mothers, 492 public awareness and education prevention Family Connections, 490-491 messages, 472 for fathers, 493-494 sexual abuse, 472-473 Hana Like Home Visitor program, 489 shaken baby syndrome, 475 Healthy Families Georgia, 490 warning signs, 472-473 Iowa First Steps, 492 violence-related, 496-501 Iowa Stork’s Nest program, 492-493 HOPE! Drama Troupe, 497, 500 Project Healthy Grandparents program, 492 QuickThink board game, 497, 500 SafeCare program, 491 Second Step Violence Prevention program, 497, 498 new directions in, 471-472 Spider-Man resource, 497, 499, 500 for parents, 485-489 Steps to Respect, 497, 499 Circle of Parents, 488-489 Talking About Touching, 497, 499 Crying Program, 485-486 Woven Word family book, 497, 501 First Steps, 485 Primary prevention, 469 helpline, 487 Prioritizing in prevention, 478-479 Parents Anonymous, 488-489 Professional education in prevention, 481-485 Period of PURPLE Crying, 486-487 Professional organizations Stages of Crying, 486-487 American Professional Society on the Abuse of Children, professional education, 481-485 503-504 advice to professional, 482 International Society for Prevention of Child Abuse and American Professional Society on the Abuse of Neglect, 504 Children, 483-485 National Center on Shaken Baby Syndrome, 505 APSAC Advisor, 484-485 National Children’s Alliance, 505 Colleagues for Children, 483, 484 National Clearinghouse on Child Abuse and Neglect conferences, 484, 485 Information, 503 emerging practices, 481 Prevent Child Abuse America, 505 Mandated Reporters Guide, 483, 484 Program, graphics, 2 parent training, 481 Progression from abuse to killing of abuser, 403-407 Power of Prevention, 484 Project Healthy Grandparents, 492, 496 Prevent Child Abuse America conference brochure, Projection, hymenal, 236, 245, 248 484 Prolapsed urethra, 234 Prevent Child Abuse Georgia conference brochure, Prolapsed uterus, 234 484 Prominent urethral support structures, 247 Quarterly Update, The, 483 Prone knee-chest position, 228 Right on Course, 482 Prosecutor, demonstrations used by, 465-467 shared leadership, 485 Proximal humerus fracture, 188 Spider-Man resource, 482-483 Proximal humerus metaphyseal injury, 225 standards for prevention programs, 481 Proximal tibial fracture, 219-220 range of, 470-471 Pseudocyst, pancreatic, 186, 223 resources for parents, 494-495 Puberty, hymenal changes in, 230-232 Before You Leave Your Kids with Your Boyfriend, Public will for prevention, 476 494 Publications, 508-510 Children Home Alone, 495 of American Professional Society on the Abuse of How to Help Kids Stay Safe, 494 Children, 483-485 Report Card Time, 495 APSAC Advisor, 509 What Do I Say Now?, 494 APSAC Practice Guidelines, 509 strategies for, 472-476 Child Maltreatment, 508 blue ribbon symbol, 476 of International Society for Prevention of Child Abuse bullying, 476 and Neglect car safety, 476 International Journal of Child Abuse & Neglect, 510 Elijah’s Story, 475 The Link, 510 general messages, 475 Quarterly Update, The, 508 Georgia adult responsibility advertisement, 473 Pulling of hair, 21 Massachusetts media campaign, 473 Punching injury, 222 physical and emotional abuse and neglect, 474 Punctate lesion Prevent Child Abuse Georgia, 474 band of, 32

542 Index

behind ear, 33 Recommendations for interrogation of caregivers, 330 Puncture wound Rectal fissure, 49 anal, 49 Rectal injury in infant, 253 postmortem, 314, 315 Rectum PURPLE crying program, 486-487 laceration extending to, 36 Purpura, Henoch-Schönlein, 61 postmortem, 439 Reducing Child Maltreatment: A Guidebook for Parent Services, Q 482 Quarterly Update, The, 483, 508 Redundant hymen, 230 QuickThink board game, 497, 500 Referral of bite injury, 192 Reflective representation R aspects charts as, 389-390 Radial fracture, healed, 220 of client's attitude, 388 Radiator burn, 102-104 variant artistic expression as, 388 of buttocks, 103 Reframing issues in prevention, 472 of foot, 102 Regression, evident in drawing, 395 of leg, 103 Rehabilitation, nutritional, 275 Radioisotope study of cerebral edema, 171 Remnant, septal, 230, 232 Radiology Report, forensic entomology, 314 bone scan, 213, 447 Report card, 495 of rib fracture, 222 Reporting of bite, 191 in diagnosis of abuse, 213-215, 225-226 Reproductive structures, duplication of, 239 in documentation of abuse, 447-449 Resource, 503-510 of fracture, 213-226 conferences as, 506-508 bucket-handle, 214, 218 professional organizations as, 503-505 chronic, 219 publications as, 508-510 clavicular, 214, 217 for safety, 494-496 of corner of bone, 214, 220, 225, 226 Restraint, cord injury from, 47 in diagnosis of abuse, 220 Reticuloendotheliosis, 37 of elbow, 216-217 Retinal examination, 443 femoral, 216, 220, 225-226 Retinal hemorrhage, 211 humeral, 216, 225 in head injury, 143, 163 knee, 218, 220 in shaken baby syndrome, 205-210, 212 metaphyseal, 218-219, 225, 226 Retinal schisis cavity, 143 multiple, 140, 217, 220-222, 225-226 Retroperitoneal bleeding, 326 overview of, 213-215 Retropharyngeal abscess, 320 parietal bone, 153 Rib, callus formation on, 54, 176, 189 radial, 186, 220, 304, 433 Rib fracture, 175-176 rib, 217, 220-223, 226, 447 bone scan of, 222 skull, 140, 448 in death, 325 spiral, 216 documentation of, 447 supracondylar humeral, 216 hemothorax and, 185 tibial, 219, 225 indicative of abuse, 215 ulnar, 186, 220 in infant, 217, 220 of various ages, 220, 221 insufficient history with, 183-184 wrist, 186 multiple, 183-184, 217, 220-221, 226 periosteal stripping, 226 other fractures with, 189, 218 of punching injury, 222 photodocumentation of, 433 of ruptured pancreas, 223 radiographs of, 185, 188-189, 217, 220-221 of spine, 226, 448, 449 stomping injury causing, 189 of stomping injury, 221 Rickets, chronic metaphysitis vs., 214 fatal, 224 Ridge, intravaginal, 243, 246 whole body roentgenogram, 447 photodocumentation of, 440 Radius, fracture of, 186, 304, 433 Right on Course, 482 Rape, alleged, 258 Rim, posterior hymenal Rash, monilial, neglect of, 274 intact, 247 Reaching Your Goals: Administrative Standards, 482 normal, 238, 248

543 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

Ritualistic paraphernalia, 381 crescentic hymen in, 241 Roentgenogram, whole body, 447 cribriform hymen in, 250 Role of medical examiner, 287 curling iron burns on, 92 Rolling off bed by infant, 445 digital penetration of, 264 Rope mark dog bite on, 35, 197-198 in accidental near strangulation, 56 duplication of reproductive structures in, 239 from binding, 20 estrogenized hymen in, 249 from garroting, 15 hymenal pit in, 251 Rugae, intravaginal, 248 hymenal projection in, 245, 248 estrogenization and, 250 immersion burn of, 73-82 Ruler, for documentation of abuse, 444-446 intact posterior rim in, 247 Rupture intravaginal ridge in, 243 of duodenum, 224 lichen sclerosis in, 239 eardrum, 46 multiple bruises in, 6-7, 11 blood from, 14 multiple injuries in, 20, 183 of intracranial aneurysm, 138 nutritional neglect of, 281-282 pancreatic, 223 patterned injury in of retropharyngeal abscess, 320 on back, 19 to face, 19 S to hand, 18 SafeCare program, 491 to leg, 16-17 Safety to neck, 15 drawing depicting fear for, 411 to thigh, 17 resources for, 494-496 penetration of, 252, 263 Safety neglect perianal streptococcal injection in, 262 dog bite and, 35 precocious puberty in, 249 institutional, 55 prolapsed uterus in, 234 Salivary swab of oral injury, 192 septate hymen in, 232 Saucepan injury, 4 transected hymen in, 253, 264 Scab on bite mark, 200 vaginal duplication in, 235 Scald injury, 83-89, 132-133. See also Burn injury, vitiligo in, 235 immersion; Burn injury, scald wringer washer burn of, 106 Scale for photo of injury, 193, 200 Scissors, 267 Scalp Scleral hemorrhage, 422 bruising beneath, in fatal head injury, 146 Sclerotic line, 220 cigarette burn on, 108 Scorpion, 381-382 contusion of, 53, 150, 151, 176 Scratch pitting edema of, 5 on knee, 293 subgaleal hematoma of, 137 self-inflicted, 312 subgaleal hemorrhage and, 139 Scrotal condyloma accuminata, 261 Scan, bone Scrotum as documentation, 447 battery burn of, 119 in metaphyseal injury, 213 beating injury from cue stick, 311 of rib fracture, 222 bruise on, 10 Scar curling iron burn of, 96 from belt injury, 25 ecchymosis of, 34 on chest, 102 Second Step Violence Prevention program, 497-498 in Ehlers-Danlos syndrome, 65 Secondary prevention, 469 from looped cord injury, 41 Seizure in shaken baby syndrome, 208 Scarred linear mark, 37 Self-induced mark, 66 Scarred loop mark, 37 Self-inflicted scratch, 312 Scarring of immersion burn, 126, 128-129, 131 Self-strangulation, 55 Schisis cavity, retinal, 143 Senna laxative, 114 School-aged child Sensitivity of radiograph, 213 anal laceration in, 256 Separation, epiphyseal, 214 annular hymen in, 241, 244 Septal remnant, 232 belt injury to, 16 Septate hymen, 232

544 Index

September 11, drawing depicting, 394 anal, 243 Septum, in hymenal opening, 230 anal tag, 242 Settings, 510-516 anal venous pooling, 244 child advocacy center as, 510-514 annular hymen, 229-230, 232, 241-242, 244 courtroom as, 515-516 anterior intravaginal ridge, 246 Severe neglect, 280-286, 320 circumferential hymen, 244 Sexual abuse, 227-264 crescentic hymen, 229, 241, 243, 247, 255 acute findings in cribriform hymen, 250-251 alleged rape, 259 estrogenized hymen, 242-243, 245-246, 249, 250 anal hematoma, 260 hymenal integrity, 246 anal laceration, 256 hymenal mound, 243, 246, 249 anal tears, 253 hymenal pit, 251 bleeding after penetration, 258 hymenal projection, 230, 245, 248 genital bleeding, 255 hymenal tag, 248, 251 hematoma, 253 intact posterior rim, 247 hymenal tear, 253 intravaginal ridge, 243, 246 labial intercourse, 258 intravaginal rugae, 231, 248, 250 laceration, 254 in knee-chest position, 229, 232, 243, 247, 249 laceration after penetration, 257 large urethral opening, 241 laceration with bruising, 257 midline white line, 245 partial hymenal healing, 253 normal hymen, 242 penetration, 256 with penetration, 252 penile bruising, 259 posterior hymenal rim, 248 penile burn, 259 posterior mound with cleft, 249 perianal bruising, 259 precocious puberty, 249 perianal laceration, 257, 259 prominent urethral support structures, 247 straddle injury-related bruising, 258 smooth avascular posterior area, 245 traumatic hymenal laceration, 256 thickened crescentic hymen, 243 drawing of, 338 vascularization, 250 by grandfather, 395 with and without traction, 251 of internalization of emotions and guilt, 397 old injury from regression and agitation in, 395 digital penetration, 264 relating story of, 396 healed transection of hymen, 264 showing hypervigilance and fear, 396 penile penetration, 263 to work through therapeutic stages, 398 oral injuries in, 191 examination techniques for, 228-229 overview of, 227-228 in fatal injury, 203 prevention strategies for, 472 findings confused with, 233-240 Sexual activity, drawings of, 338, 395-399 duplication of reproductive structures, 235, 239 Sexually transmitted disease external hymenal midline, 237 condyloma acuminata, 260 failed midline fusion, 234, 237 flat warts, 262 foreign body, 236, 238 hemorrhagic herpes, 261 hemangioma, 240 molluscum contagiosum, 263 hymenal projection, 236 penile lichen planus, 262 imperforate hymen, 233 perianal condylomata, 261 labial bruising, 239 perianal herpes, 260 labial fusion, 234, 237 perianal streptococcal infection, 262 lichen sclerosis, 233, 239 scrotal condyloma acuminata, 261 pinworm, 240 Shaken baby syndrome prolapsed uterus, 234 conference on, 508 straddle injury, 235 death from, 327 vaginal duplication, 235, 239 demonstration of, 465-467 vitiligo, 235, 240 drawing depicting, 412 hymenal configurations and, 230-232 imaging of, 148, 169 medical examiner's investigation of, 313 ophthalmology in, 205-212 normal findings and hematoma and, 209 after abuse, 245 macular hemorrhage and, 210

545 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

overview of, 205 Social autopsy, 476 papilledema and, 210 Sock, band mark from, 20, 61 retinal hemorrhage and, 210-211 Sofa, height of, 445 seizure and, 208 Soft tissue injury, 25, 27, 325 optic nerve injury in, 143 Space, subarachnoid, bleeding into, 138 prevention programs for, 475 Space heater burn spinal radiographs in, 448 accidental, 116 Shaking injury, skull fracture with, 156 of back, 103 Shared leadership in prevention, 485 of buttocks, 103-104 She Has a Friend advertisement, 473 of foot, 102 Sheath, optic nerve, 143, 163 Space heater next to crib, 271 Shin Specificity of radiograph, 213 bite mark on, 307 Spider-Man resource, 482-483 bruise on, 4, 307 for fathers, 494 Shoe, patterned injury from, 7 for violence prevention, 497, 499, 500 Short stature, 461-462 Spill, accidental burn from, 117, 118 Shoulder on chest, 119 accidental injury to, 64 Spinal cord, cervical, epidural hemorrhage overlying, 172 contact burn, 115 Spine, radiology of, 448 spill burn, 118 Spiral fracture, femoral, 216 beating injury of, 336 Splash burn from acid, 112 brand on, 111 Splenium of corpus callosum, hemorrhage in, 169 bruises on, 4-5, 51 Splint, bruise caused by, 431 in neglect case, 346 Spoon, beating with, 336 contact burn on, 94, 107-108, 111, 115 Spot, Mongolian, 23, 62 curling iron burn of, 94 on back, 294 scald burn of, 84, 133 on buttocks, 38, 59 Siblings, abused, 305-307 on leg, 20 SIDS, 287, 345 as skin discoloration, 295-296 Sign, Battle's, 39 Squeezing, liver laceration from, 178 Sitting frog-leg position, 228 Squeezing injury, 291-292 Skeletal survey, 447 Stages of Crying program, 486 Skin Stairway bruise on, 2-14. See also Bruise in crime scene reconstruction, 288-289 discoloration of, 291, 295-296 unsafe, 272 in Ehlers-Danlos syndrome, 62 Standard for prevention programs, 481 overview of injuries to, 1 Standardized growth chart, 457-459 patterned injury to, 14-37. See also Patterned injury Starvation, death by, 316-318 Skull Stature-for-age chart, 456, 458 increased intracranial pressure and, 138, 148, 152 Steps to Respect, 497, 499 as protection, 137 Sternum, bruise on, 301 Skull fracture Stick injury to eye, 35 basilar, 150 Still image from digital video, 437-438 diastatic, 447-448 Stocking-glove burn pattern, 70-72 in fatal head injury, 157 Stomping injury, 180, 221 from impact on table, 157 fatal, 224 multiple, 140, 154-155, 177 Storage rooms of child advocacy center, 514 occult, 151 Stork's Nest program, 492-493 overview of, 137 Storytelling, drawing as foundation for, 394 shaking injury and, 156 Stove Slamming injury burns from, 105, 112, 135 head, 149 in domestic dispute case, 364, 379 parietal lobe laceration from, 170 in environmental neglect, 269 Slap mark, 74 Straddle injury, 235 on infant, 14 bruising in, 258 Small intestine injury, 180 to scrotum, 65 Snake, 382 Strangulation, attempted, 55-56

546 Index

Streptococcal infection, perianal, 262 Stretch marks, differentiation of, 421 T Table corner injury, 157 Strike mark, 349 Tag, hymenal, 248 Stripping, periosteal, 215 Talking About Touching, 497, 499 in femur, 226 Tandberg HC3, 454 Strong Communities program, 477-478 Tanner stage 1 hymen, 229 Subarachnoid hemorrhage Target organ computed tomography of, 162 abdomen as, 46 in parasagittal region, 163 buttocks as, 38, 46 subdural hemorrhage with, 165 ear as, 39, 44-46 Subarachnoid space, bleeding into, 138 eye as, 42, 43, 46 Subconjunctival petechial hemorrhage, 321 face as, 43-44 Subdural fluid collection, 159 hand as, 37, 41 Subdural hematoma, 8, 44 lip as, 39-40 bilateral, 161 mouth as, 39-40, 42 chronic, 144-145, 158 Tartu, Estonia in fatal head injury, 150 child advocacy center in, 514 as hallmark of abusive head injury, 137-138 court in, 516 hyperintense, 161 Tear interhemispheric, 159 anal, 49, 52, 253 hyperdense, 167 of frenulum, 44, 50 multiple, 161 in fatal injury, 141, 322 old, 160 hymenal, in sexual abuse, 253 parietal, 435 Teddy bear in demonstration, 465 in shaken baby syndrome, 206, 208-209 of shaken baby syndrome, 467 Subdural hemorrhage, 54, 171, 176 Teeth as target organ, 40 in fatal injury, 141, 146, 147, 150, 163 Teeth mark, 14. See also Bite mark subarachnoid hemorrhage with, 165 Teleconferencing, 453-454 Subgaleal contusion, 177, 183 Temperature Subgaleal hematoma, 149 cooking, 68 from shaking, 148 measurement of, 446 from slamming, 149 Temporalis muscle, hemorrhage in, 164 Subgaleal hemorrhage,53 Tertiary prevention, 469 in fatal injury, 139, 142, 147 Theory of lucid interval, 137 skull fracture with, 154-155, 157 Therapeutic stages, drawing showing, 398 Subretinal hemorrhage, 165 Therapy room of child advocacy center, 512 Suck blister, 63 Thermometer, 446-447 Sudden infant death syndrome, 287, 345 Thickened hymen, 230 Suffocation, fatal, 141 Thigh Summit, advocacy, 479 abrasion on, 306 Superficial hymenal laceration, 256 beating injury from cue stick, 311 Supervisory neglect, 265, 266-268 beating with radio antenna, 308-310 documentation of, 455 belt injury to, 16, 24, 30 Support structures, urethral, 247 bite mark on, 299, 306 Supracondylar fracture, humeral, 216 bruise on, 301, 309-310 Suture in school-aged child, 11, 17 at base of penis, 290-291 burn on, 18 cerebral edema and, 327 accidental, from spill, 117 increased intracranial pressure and, 148 cigarette, 99 Swab of oral injury, 192 contact, 107 Swainsboro, Georgia, child advocacy center, 510 fireworks, 101 Swelling flame, 112 of brain, 150, 165, 176, 177 scald, 89 in Henoch-Schönlein purpura, 61 contusion on, 306 Switch, beating with, 312 ecchymotic area on, 81 Swollen prepuce, 31 linear marks on, 31, 35

547 Child Maltreatment—A Comprehensive Photographic Reference Identifying Potential Child Abuse

loop mark on, 24, 31, 35 fatal injury to, 146-147 Thoracic injury, 173 hand mark on, 29 Thoracic spine, 448, 449 head circumference-for-age chart for, 458 Thoracoabdominal trauma, 173-189 hypoxic injury in, 168 attributed to CPR, 182 immersion burn of, 76, 78, 79, 80, 81 chest contusions as, 177 bathtub, 122-123 computed tomography of, 185-186 of perineum, 124 duodenal, 179, 187 stocking-glove, 124 insufficient histories with, 183-184 length-for-age chart for, 457 liver laceration as, 178 medical neglect of, 274 to lung, 174-175 mesenteric contusions in, 177 overview of, 173 midline white line in, 245 radiography of, 187-189 Mongolian spots on, 293-295 rib fracture as, 176. See also Rib fracture multiple injuries to, 51, 52 ruptured blood vessels from, 181 burn, 134 to small intestine, 180 contusion, 24 upper gastrointestinal studies of, 187 nonabusive skin lesions on, 293-295 Thorax nutritional neglect of, 277-278, 283-286 accidental injury to, 64 penile laceration in, 290-291 belt injury to, 19 perianal bruising in, 259 Three-dimensional representation, 393 police investigation of injuries, 331 of oral injury, 192 scald burn of, 83, 86, 87 Thunderclap headache, 138 multiple, 84 Tibial fracture scrotal injury to, 96 bucket-handle, 218 skull fracture in, 177 burn with, 80 spiral femoral fracture in, 216 corner, 225 stomping injury to, 189 proximal, 219 subdural hemorrhage in, 163 Tissue volume loss in brain, 168 subgaleal contusion in, 177 Toddler supracondylar humeral fracture in, 216 anterior intravaginal ridge in, 246 swelling of brain in, 177 asphyxiation of, 320 traumatic asphyxiation of, 28 avulsed tooth in, 9 Toe beating injuries to, 43 binding injury of, 20 bite mark on, 201, 202, 297-299 bruise of, 51 bruise on, 33, 305 frostbite of, 113 abdominal, 9 Toilet, unsanitary, 269, 270, 285 on arm, 4 Tooth facial, 2, 4, 9, 10 avulsed, 9 labial, 239 laceration from, 40 burn injury to. See also immersion burn of, below as target organ, 40 accidental, 116, 118 Torn frenulum, 44, 50 cigarette, 100 in fatal injury, 141 contact, 90, 109 Torso curling iron, 93, 94, 97 curling iron burns on, 92 multiple, 110, 134 scald burn of, 83 space heater, 104 Torture from spill, 118 of developmentally disabled child, 29 stocking-glove pattern of, 71, 72 loop marks and burns in, 18 chest contusions in, 177 Toxic agent, in supervisory neglect, 266 death of, from natural causes, 330-332 Traction dots on skin of, 22 examination with and without, 251 duodenal injury to, 179 labial, 228-229 facial bruising in, 9 Transected hymen, 253, 264 fall injury in, 435 Transected jejunum, 180 fall through balusters by, 288-289 Trash can, in investigation, 360, 364, 380 fatal head injury in, 146 Trash in home, environmental neglect and, 270, 272, 273

548 Index

Traumatic asphyxiation, 28 perianal, 240 Traumatic metaphysitis, 214, 225, 226 Vitreous, 143 Traumatic superficial hymenal laceration, 256 Volume loss, brain tissue, 168 Trunk bruise, 324 Vomiting Twisting of ear, 39 facial injury with, 44 multiple injuries with, 51 U Ulnar fracture, 186, 304, 433 W healed, 220 Waiting room of child advocacy center, 511 Ultrasonography of subdural hematoma, 160, 161 Wall, chest, squeezing injury of, 291-292 Ultraviolet light filter for Mongolian spots, 293-296 Warning signs, prevention strategy and, 472-473 Unattended child, supervisory neglect and, 266-268 Wart, flat, 262 Uncal herniation, 167 Washer, wringer, burn from, 106 Unheated apartment, environmental neglect and, 272 Wasting, 317-318 Universal parental support program, 485 of muscle and fat tissue, 277 Unresponsive victim, 206-207 Water heater, investigation of, 378 Unsanitary toilet, neglect and, 269, 270, 285 Water line in immersion burn, 127 Upper gastrointestinal studies, 187 Water temperature, 446-447 Urethra, prolapsed, 234 Web site for growth charts, 456 Urethral opening, large, 241 Weight gain, catch-up, 464 Urethral support structures, prominent, 247 Weight-for-age chart, 456, 458 Urine, battery burn and, 119 in failure to thrive, 460 Uterus, prolapsed, 234 in feeding difficulty, 463 inadequate feeding and, 464 V in short stature, 461, 462 Vaginal bleeding Welch Allyn Zoom Scope, 416-417 after digital penetration, 436 What Are Your Priorities booklet, 479 after penile penetration, 258 What Everyone Can Do to Prevent Child Abuse, 478, 479 Vaginal discharge When She's Only Five, It's Not Sex advertisement, 474 in prepubertal child, 232 White line, midline, 245 significance of, 230 White matter, hyperdensity in, 169 Vaginal duplication, 235 Whole body roentgenogram, 447 Vaginal injury in fatal trauma, 203 Wiring, in investigation, 375 Vaginal laceration, 257 Witness, drawing of Vaginal penetration, old injury from, 263 gunfight, 402 Vascularization, 250 infant's death, 413 Venous pooling, anal, 244 Worksheet, evidence, for immersion burn, 446 Video camera, 415-416 World events, drawings of, 394 Video photography, 440, 455 Worry, drawing expressing, 390-391 Violence Wound, gunshot, 324 interpersonal, drawing of, 386, 399-407 Wound infection, neglect and, 280 before and after conscious memory of, 400-401 Woven Word family book, 497, 501 of anger, hostility, and aggression, 399 Wringer injury, result of, 21 before conscious memory of, 400 Wringer washer, burn from, 106 of killing abuser, 402-407 Wrist, fracture of, 186 witness to gunfight, 402 Writing, as alternative to drawing, 388 prevention programs for HOPE! Drama Troupe, 497 Y QuickThink board game, 497, 500 Yard of home, in investigation, 383 Second Step Violence Prevention program, 497, 498 Spider-Man resource, 497, 499, 500 Z Steps to Respect, 497, 499 Zeiss colposcope, 415 Talking About Touching, 497, 499 Woven Word family book, 497, 501 Visceral bleeding, 326 Visual environment cueing, 391 Vitiligo, 235

549