PAC 414 Module 2 Recognizing Signs of Abuse Example

Aiden's Left Ear: How a Home Visitor Recognized a Warning Sign of Physical Abuse in a Three-Month-Old

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 414: Child Abuse and Neglect

Instructor Name

Month Day, Year

Aiden's Left Ear: How a Home Visitor Recognized a Warning Sign of Physical Abuse in a Three-Month-Old

On a Tuesday morning, a home visitor from Heartland Family Services, the invented Wichita agency in these papers, arrived for a scheduled visit with Brianna, twenty-two, nine months into recovery from methamphetamine use, and her three-month-old son, Aiden. As she held Aiden, the visitor noticed a small bluish bruise on the rim of his left ear. Brianna said he must have bumped it on the crib slats. Aiden cannot yet roll over. The visitor had to decide what the bruise meant and what to do. This paper reviews the research that guided her. Aiden and his family are composites made for teaching; the research is real.

Why Age and Mobility Matter

Bruises are common in children who are walking. Toddlers fall constantly, and bruises on the shins, knees and forehead, the bony surfaces that hit the ground, are expected. Infants who cannot yet roll, crawl or pull to stand rarely bruise accidentally, because they do not move enough to injure themselves. This simple principle, often summarized as "those who don't cruise rarely bruise," underlies much of the research on recognizing abuse in young children.

Sentinel Injuries

Sheets et al. (2013) reviewed the records of infants evaluated for physical abuse at a children's hospital. Among infants with definite abuse, more than a quarter had a previous sentinel injury, a minor visible injury such as a bruise or an injury inside the mouth, that had been seen by a caregiver or medical provider before the abuse was recognized. Such injuries were very rare among infants for whom abuse was ruled out. Many sentinel injuries had been noticed but not acted on. The authors concluded that minor injuries in young infants should prompt evaluation, because recognizing them could prevent more serious abuse.

Bruising Patterns

Pierce et al. (2010) compared bruising in children admitted to pediatric intensive care units for trauma, some with abusive and some with accidental injuries. They developed a rule that discriminated abuse from accidents with high accuracy. Bruising on the torso, ears or neck in a child under four years, or any bruising at all in an infant under four months, was strongly associated with abuse. The rule became known by the abbreviation TEN-4 and is widely used as a screening guide. Pierce and colleagues stressed that the rule identifies children who need evaluation, not children who have definitely been abused.

Aiden's bruise meets two parts of the rule: it is on the ear, and he is younger than four months.

Fractures

Kemp et al. (2008) systematically reviewed studies of fractures in children to identify patterns that distinguish abuse from accidents. Rib fractures had the highest probability of abuse among the fractures studied, particularly in young children. Fractures in children who were not yet walking warranted careful evaluation, and certain fractures of the long bones in infants and toddlers were associated with abuse. Multiple fractures and fractures of different ages also raised concern. The authors noted that the probability of abuse depended on the child's age and developmental stage and recommended a skeletal survey, a series of X-rays, for young children with suspected abuse to look for hidden fractures.

Warning Signs by Age and Mobility

The Visitor's Response

The visitor did not try to determine on her own whether Aiden had been abused. She told Brianna calmly that bruises on babies Aiden's age need to be checked by a doctor, because babies who cannot move rarely get bruised, and that this was her practice with every family. She called her supervisor from the home, and together they arranged for Aiden to be seen that day at the pediatric clinic. Kansas law requires professionals who suspect abuse to report, and the supervisor and visitor agreed that a bruise meeting the TEN-4 criteria in a three-month-old warranted a report to child protective services. The visitor told Brianna before making the report, explained what would happen next and said she would continue visiting. She documented what she saw, Brianna's explanation in her own words and every step taken.

At the clinic, the pediatrician ordered a skeletal survey and blood tests. The evaluation would determine whether there were other injuries or a medical explanation, such as a bleeding disorder.

Talking With Brianna

The hardest part of the visit was the conversation with Brianna. She was frightened and defensive, and she said, "You think I hurt him." The visitor answered that she did not know how the bruise happened, that it was not her job to decide and that she was asking the doctor to look because that is what she does with every baby this age who has a bruise. She acknowledged how scary a report must feel, especially for a parent in recovery who has worked hard to keep her son, and explained that a report starts an assessment, not a removal. She told Brianna what the doctor would likely do and offered to drive them to the clinic. That conversation, honest and steady, kept the relationship intact while the evaluation went forward.

Recognizing Without Assuming

Recognizing a warning sign is not the same as concluding that abuse occurred. Some infants with bruises have medical conditions, and some explanations are true. The visitor's job was to recognize that the bruise required evaluation and to make sure it happened, not to judge Brianna. Her history of methamphetamine use did not determine the response; the bruise did. A visitor who treated every parent in recovery as a suspect would lose their trust, while a visitor who ignored a bruise in an immobile infant could miss a sentinel injury.

Conclusion

A bruise on a three-month-old who cannot roll over is a warning sign that requires evaluation. Sheets and colleagues show that such minor injuries often precede serious abuse, Pierce and colleagues show which bruises discriminate abuse from accidents and Kemp and colleagues show which fractures most suggest abuse. The home visitor recognized the sign, arranged medical evaluation, reported as required and kept her relationship with Brianna, which is what the research and the law ask of her.

References

Kemp, A. M., Dunstan, F., Harrison, S., Morris, S., Mann, M., Rolfe, K., Datta, S., Thomas, D. P., Sibert, J. R., & Maguire, S. (2008). Patterns of skeletal fractures in child abuse: Systematic review. BMJ, 337, a1518. https://doi.org/10.1136/bmj.a1518

Pierce, M. C., Kaczor, K., Aldridge, S., O'Flynn, J., & Lorenz, D. J. (2010). Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics, 125(1), 67-74. https://doi.org/10.1542/peds.2008-3632

Sheets, L. K., Leach, M. E., Koszewski, I. J., Lessmeier, A. M., Nugent, M., & Simpson, P. (2013). Sentinel injuries in infants evaluated for child physical abuse. Pediatrics, 131(4), 701-707. https://doi.org/10.1542/peds.2012-2780