Recognizing signs of child abuse can save lives

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Dr. Amanda Brownell is a child abuse pediatrician and medical director of the Spurwink Center for Safe and Healthy Families in South Portland. She is also a clinical assistant professor at Tufts University School of Medicine, Maine Medical Center and a member of the Maine Child Death and Serious Injury Review Panel.

If you are concerned that a child is being neglected or abused, call Maine’s 24-hour hotline 800-452-1999 or 711 speak to a child protection specialist.

For every death from child abuse that is reported in the news, for every case that is reviewed at the government level and given public attention, we must be aware that there are many more children suffering from abuse that never comes to light Headlines are coming. Fortunately, there is a simple but effective assessment tool called the TEN-4 that can help those caring for children identify early signs of abuse.

According to published national data, more than one in three children will be subject to a child protection investigation by the age of 18. More than one in ten children is involved in justified abuse. As a child abuse pediatrician, my colleagues and I care for Maine’s children suffering from abuse.

Individuals and organizations working with children and their families are thinking about ways to keep children safe and prevent child abuse. Themes for intervention often emerge, such as identifying children in high-risk situations before the child experiences devastating trauma and attempting to reduce the risk of harm. Another possible intervention is to detect subtle signs of physical abuse earlier to allow for immediate intervention and prevent worsening or ongoing abuse.

It is the last idea, the idea of ​​identifying sentinel injuries, that has driven much research in the field of pediatrics and that now bears its name on October 4th, TEN-4 Awareness Day.

In 2013, a study from the Medical College of Wisconsin was published describing 200 severely abused infants less than 12 months old. An astonishing 27.5 percent of them had previous injuries that doctors should have recognized as evidence of abuse. The authors concluded: “Previous sentinel injuries are common in infants with severe physical abuse and rare in infants screened for abuse and found not to have been abused.” The detection of sentinel injuries through Appropriate interventions could prevent many cases of abuse.”

Despite the published literature on sentinel injuries, misdiagnosis of abuse continues to occur. My colleagues and I see this in our clinical practice in Maine. To help medical professionals more confidently identify concerning injuries in young children, a research study published in 2021 examined over 2,000 children who underwent abuse evaluations over a four-year period. The authors developed a validated “clinical decision rule for bruising” that correctly identified most abuse victims with high sensitivity and specificity and, equally important, correctly identified those who were not abused.

This tool is a simple injury identification acronym, TEN-4-FACESp:

These are bruises on the trunk, ears, neck, labial frenum, angle of the jaw, cheek (fleshy area), eyelid and subconjunctiva (the white of the eye) in children under 4 years of age. This includes bruising anywhere in children 4 months old and younger, as well as bruising in a pattern, such as on the hand or belt.

The authors noted that such findings, even if they do not independently indicate abuse, warrant further evaluation, such as by a child abuse pediatrician. Although seemingly minor injuries, these external signs of possible abuse may be the only indication that a child is in an unsafe environment.

Subsequently, the authors proposed marking October 4 (TEN-4) as TEN-4 FACESp Awareness Day and suggested the introduction of hospital child abuse awareness campaigns, childhood abusive head trauma training, and TEN-4 media days before. This year, Governor Janet Mills and the State of Maine will join several other states in recognizing October 4th as TEN-4 Awareness Day.

It takes all of us to protect children and prevent ongoing abuse and potential deaths. Anyone who cares for children should be able to identify potential injuries early and then take steps to prevent further abuse. In addition to reporting to Child Protective Services, these children should always receive medical evaluations from the most trained and experienced medical providers available, such as board-certified child abuse pediatricians, including those at the Spurwink Center for Safe and Healthy Families.