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“On average, nearly 20 people per minute are physically abused by an intimate partner in the United States.During one year, this equates to more than 10 million women and men.” Stated Project Sanctuary, Domestic Violence is violent or aggressive behavior in the home, typically involving the violent abuse of a spouse or partner. This is […]
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Get startedDiagnostic imaging of child abuse is focused on the advanced modalities as well the understanding of the definition of child abuse and the different forms. Many factors contribute to child abuse that may increase the risk and have the ability to make children more vulnerable to abuse. If suspicion arises that a child has been abused, ensuring a child’s safety is the first priority. The assessment of suspected child abuse relies greatly on the use of diagnostic imaging. The role of imaging is to identify the extent of the injury as well as identifying any abnormal findings that point to an alternative diagnosis. More specifically, Diagnostic x-ray, Computed tomography, and magnetic resonance imaging are the modalities used to evaluate if child abuse has transpired.
In the United States, more than four children die from child abuse and neglect on a daily basis. Over 70% of these children are below the age of three11. Abused children encompass more than bruises and broken bones. Even though the eye can see physical abuse, other types of abuse such as emotional and sexual abuse, have the ability to leave deep, long lasting scars. Diagnostic imaging for child abuse, plays an important role to identify the degree of physical injury when abuse is suspected and to ensure quality in all imaging modalities that will help point to a diagnosis.
Effective diagnostic imaging of child abuse relies on high-quality technology as well as experienced technologists and radiologists who work together to come up with the appropriate diagnosis. Imaging modalities, including diagnostic x-ray, computed tomography (CT), and magnetic resonance imaging (MRI) have the ability to provide an internal evaluation of child abuse. Although each modality is somewhat restricted, they each have certain qualities that are critical in determining whether abuse has transpired and the next appropriate steps.
Children of all ages can become victims of abuse and neglect. However, those younger than four are at a higher risk for serious injury or death. Child abuse is widespread and can occur in any cultural, ethnic, or income group. Child abuse can be physical, emotional, and/or sexual. This can be seen between direct contact with the child and abuser, or it can be seen as neglect. Child neglect can occur when the child does not get provided the necessities needed for life either by intentional doing or with reckless disregard. Abuse can end with serious injuries to the child and in some cases, death.
Physical mistreatment is one of the most common forms of child abuse. This type of abuse is a non-accidental act that results in physical injury inflicted upon the child with cruel and/or malicious intent. This frequently happens when a person is either angry or frustrated causing them to beat, shake, or throw a child. Figure one demonstrates a child being slapped; other intentional abuse is burning, cutting, twisting limbs, or otherwise torturing a child. More specifically, abusive head trauma or shaken baby syndrome can be a result of this form of cruelty. Shaken baby syndrome is one of the leading causes of death in child abuse cases with in the U.S. In most incidents, all it takes is a few seconds of abuse to cause the child to have brain damage that will affect the child for the rest of their life. Figure 1. A child who has been a victim of physical child abuse.
Shaken baby syndrome is a serious form of abuse that can be inflicted upon a baby. The term “shaken baby syndrome” was developed to explain those instances in which severe intracranial trauma occurring in the absence of external head trauma. This arises when the baby violently gets shaken repeatedly which can cause brain swelling, internal bleeding, mental retardation, or death. Babies have very weak neck muscles that cannot fully support their heads. As shown in figure two, severe shaking causes the baby’s head to move violently back and forth. This type of force can progressively increase if the abuser interrupts the shaking by the collision of a baby’s head a hard surface. Figure 2. Shaken Baby Syndrome.
Emotional abuse is one of the hardest forms to identify. It can be subtle and manipulative, but more importantly it can be dangerous. Emotional abuse in children is often a misunderstood form of trauma that can cause damage to a child’s developing brain, leading to long-term learning difficulties, problematic behaviors, and increased incidences of physical and mental health issues. This form of mistreatment is a display of behavior that can damage a child’s self esteem and/or sense of self-value. Emotional abuse is a way to control, in the same way that physical abuse controls a child but in a different aspect. The only difference is that the emotional abuser does not use physical beating, kicking, pushing, or other physical forms of harm. Rather the perpetrator of emotional abuse uses emotion as his/her weapon of choice. Emotional child abuse can occur in several different forms.
In can involve threatening, insulting and/or belittling words or actions to the child. In extreme circumstances, it can result in a disorder called emotional deprivation. Emotional deprivation is a syndrome that results from a lack of authentic affirmation and emotional strengthening in one’s life. This type of mistreatment is often in affiliation with other types of abuse like, physical, sexual abuse or neglect. Emotional child abuse may be the most damaging form of abuse, affecting their emotional and physical health as well as their social and cognitive development.
Sexual abuse is another form that can cause harm to a child. A child is sexually abused when they are forced or persuaded to take part in sexual activities14. This does not only occur physically, but also it can happen in a controlled atmosphere. Contact abuse occurs when the abuser touches the child, including penetration. This includes, but is not limited to, touching any part of the body, rape or penetration by putting an object or body part inside a child’s mouth or vagina, and/or making a child remove their clothes and either touch someone else’s genitals or masturbate. Non-contact abuse, on the other hand, involves non-touching activities like grooming or exploitation. It includes, but not limited to, encouraging a child to watch or hear sexual acts, allowing someone else to make, view or distribute child pornography, and/or sexually exploiting a child for money, power or status. There are many types of offenders, including trusted friends, neighbors, family, or strangers. These acts of abuse can be carried out by men or women.
The first step in helping a child is recognizing the signs and symptoms of child abuse. It is not always easy to notice if a child has been abused because the child may experience a sense of guilt, shame or may be confused about what has happened. The child may be afraid to speak out about the abuse; especially if the person who abused him/her is someone they know.
Physical child abuse ranges from unexplained injuries, such as bruises, fractures or burns to injuries that don’t match the given explanation. The signs and symptoms of emotional child abuse can vary from any change in the child’s self confidence, depression, avoidance of certain situations, such as refusing to go to school or ride on the bus, and loss of developmental skills. Lastly, the signs and symptoms of sexual child abuse are any genital pain or bleeding, blood in the child’s underwear, abdominal pain, or any sexual transmitted diseases.
Many factors contribute to child abuse, but there are certain factors that may increase the risk to children and have the ability to make them more vulnerable to abuse. A combination of individual, family, and/or community factors may contribute to the risk of a child being mistreated. Although children are not responsible for the harm inflicted upon them, certain characteristics have been found to increase their risk of being abused8. The individual risk factors affect children who are primarily under the age of four and those who have special needs like disabilities, and mental health issues. Family risk factors affect children in social isolation, negative interactions, and family violence. The final category of risk factors is in the community, where children live in disadvantaged neighborhoods such as, high poverty or unemployment rates.
Treatments of abuse help the child, as well as the parents or family members. If there is any suspicion that a child has been abused, ensuring a child’s safety is the first priority. Seeking medical attention is the next step to check for any injuries that may be critical. Physical exams, x-rays, and lab tests are a few ways that can determine medically if abuse has transpired. In the case that abuse has happened, a child can also develop physiological problems that can affect a child’s behavior, relationships, and personality. Providing a child with therapy has the ability to show them what trust is, show him/her how to manage conflict, provide ways on how to boost their self-esteem, and teach a child what normal behavior looks like and how relationships should be formed.
Diagnostic imaging plays an important role in child abuse cases because often the history provided is either incomplete or can show misleading results. Physical examinations do not always show injuries that can be involved in abuse cases. Diagnostic imaging can provide information about the injuries that could not be seen on physical examinations. The information given in these types of imaging provide high quality images obtained by quality technologists. Diagnostic imaging not only helps to identify the extent of injuries, but it also can show any medical diagnoses when abuse is not obviously present in physical appearance.
A diagnostic x-ray is the method of choice for imaging in cases of suspected child abuse. This type of imaging is relatively quick and provides no harm to a child. X- rays are a form of electromagnetic radiation that can penetrate or pass through the human body and produce shadow-like images of bones and some organs. This type of imaging shows parts of the body in different shades of black and white, which demonstrate the densities. As shown in figure three, this chest x-ray demonstrates densities such as bone, which is seen as white on the image and air, as seen in the lungs, shows up black. These x-rays have the ability to reveal abnormalities, which can show signs of disease and/or injury.Figure 3. Diagnostic child chest x-ray.
To ensure the safety of the patients, lead shields are provided to protect certain areas of the body that are more sensitive to radiation like gonads and breast tissue. The amount of radiation received during an exposure is very low, given the quick exposure time. X-rays commonly produce no adverse effects, but it is still very important to reduce the dose as low as reasonably achievable and use the appropriate shielding to protect the patients from radiation.
Generally, the amount of radiation the patient is exposed to during an x-ray is the equivalent to between a few days and a few years of exposure to natural radiation from the environment. Although levels of radiation are low, overtime multiple doses can become a risk for the creation of cancer and genetic defects, but the risk is thought to be very small. Before an x-ray is ordered, the benefits and risks will be weighed out to assure the x-ray is both necessary and the beneficial. Figure four demonstrates statistics showing the percentages of radiation received from selected sources. As shown above, medical exposure is about 20% of all the possible radiation that a person can receive overtime. This is minimal for the grand scheme of a lifetime.
If the child is suspected to have gone through physical abuse, a skeletal survey is the first step in the imaging process to focus on the entire bony skeleton. It is a series of x-rays that take images of the chest, skull, both upper arms, forearms, hands, pelvis, femurs, lower legs, ankles, and feet. Figure five is demonstrating a few x-rays that are included in the skeletal survey, but depending on the order there are around twenty images taken to gather all the information needed. A skeletal survey is very important in cases with children less than two years of age.
In children older than five years of age, a skeletal survey is unfortunately little value in screening for injuries because they are less reliable the older the age2. Skeletal surveys have the ability to help identify abnormal injuries such as a metaphyseal lesion, that occur in the long bones, and posterior rib fractures which are highly suggestive that physical abuse has transpired even when medical information is misleading. To acquire the best images, the skeletal survey is performed at the finest level using high detail imaging systems.
The images ordered follow a protocol with directions for positioning the patient (which essentially could require restraining devices like sandbags or tape) and proper centering/coning of images to the appropriate body parts needed (with shielding of others). This will ensure the images provide the details to be able to view subtle injuries of the skeletal system while keeping the patient radiation dose as low as reasonably achievable.Figure 5 Skeletal Survey.
Unlike x-rays, which uses a fixed tube, computed tomography allows the x-ray source to rotate around the body in a circular motion within the structure called the gantry. These types of scanners use a special digital detector. When x-rays are emitted through a patient they are collected by the detectors and translated to the computer. Once the scan is finished and the accurate amount of data is collected, the computer works to form 2D or 3D images that allow for location and identification of any abnormalities throughout the part of the body being evaluated.
Computed tomography, also know as CT; provide more-detailed information than diagnostic X-rays do9. It is particularly useful when imaging complex bone fractures, severely eroded joints, or bone tumors. CT can also be used to image the head in order to locate injuries, tumors, and clots leading to stroke, hemorrhage, and other conditions. This type of imaging is quick, painless, and accurate. This innovation also has the ability to use contrast agents to help see certain structures of the body better. There are two ways that contrast can be administered, either intravenously or orally. Having the contrast through an IV highlights blood vessels whereas orally highlights the digestive system.
The risk involved with using CT is directly related to the amount of radiation received. Constant or high dosages can cause genetic defects that increase over the lifespan of an individual. In addition, a CT scan does not pose any risk for a pregnant women if the area of the body being imaged is not the abdomen or pelvis16. In some cases, if the patient receives the contrast agent they have the possibility to have a reaction. If the reaction is mild, it can lead to itchiness or a rash but in very few cases, if the reaction is severe, the contrast can produce life-threatening reactions. Children are more sensitive to ionizing radiation, which may be more harmful because they are still growing and have a longer life expectancy. With that, they are at a higher risk to developing cancer over adults.
CT is the most effective and sensitive imaging technique for identifying injuries of the lungs, pleura, and solid abdominal organs. It is particularly good for assessing pancreatic injury and duodenal hematomas (blood clots in the upper part of the small intestine), two characteristic findings in child abuse. In addition, abusive head trauma is one of the main leading causes of death in children under the age of two years old, and serious neurological problems may be seen in those that survive. CT scan of the head is the imaging modality of choice when evaluating a child with acute neurologic findings or retinal hemorrhage based on the physical examination.
CT is also highly sensitive and specific for the detection of acute intraparenchymal, subarachnoid, subdural, and epidural bleeding and the consequences of these abnormalities. Shown to the right in figure six is an acute cerebral injury of a child abuse victim. A head CT scan of this victim shows a left parieto-occipital contusion, a subdural hygroma, a skull fracture, and swelling of the scalp. Most injuries caused by child abuse are easily found during these imaging studies. Figure 6. Acute cerebral injury.
There are many advantages associated with computed tomography. With speed, CT scans can be as quick as 5 to 15 minutes, in comparison to 30 to 45 minutes for an MRI scan. CT is more readily available than MRI because of the quick scanning process that can be done and the cost of a CT scan is approximately two-thirds less than the cost of an MRI scans. CT also has better imaging of bone and better detection of subarachnoid hemorrhages, which is bleeding into the ventricles, the cavities within the brain, and into the fluid that normally surrounds the brain.
There are times where the extent of injuries may sometimes be underestimated by CT imaging, which is why we do MRI scan as well. An MRI is a scan that uses magnetism, radio waves, and a computer to produce images of body structures. This type of imaging has no ionizing radiation involved. The MRI scanner is a tube surrounded by a giant magnet. The patient is placed on a moveable table that is inserted into the magnet.
The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. Lastly, the computer processes that information received and produces an image. MRI can detect very tiny changes with in the structures of the body. With certain procedures, contrast such as gadolinium, is used to enhance the accuracy of the images and visibility of certain structures.
MRI does not use ionizing radiation; therefore there is no risk of exposure during these exams. This machinery uses strong magnets that cannot be performed on patients with certain types of implants like cochlear implants, neurostimulators, certain prosthetic devices, etc. If these metals were to go through the scanner, they have the possibility of moving or dislodging from the original site in the patients body. That is because those types of devices are made with ferromagnetic materials, which have a high susceptibility for magnetization. These types of metals also have the ability to heat up which may cause risk to the patients.
In addition, there are biological side effects that can be associated with MRI like burns, hearing loss, etc. If bare skin comes in contact with the direct coils, it can cause the skin to heat up and potentially cause burning as shown in figure seven with second degree burns to the arm. Also, the noise that MRI scanners make is a vibration produced by the magnetic field reaching the auditory system causing a risk of temporary hearing loss. Overall, the best way to ensure safety during an MRI scan is to first fill out the questionnaire, thus giving the technologist all the needed information to proceed removing any metal, and hearing aides or removable dental work. Figure 7 Second-degree burn.
MRI scans come into play when typical skeletal injuries associated with shaking or impact on a child are identified. MRI has the highest sensitivity and specificity for diagnosing sub acute and chronic injury. In addition, MRI’s still remain the best modality to fully be able to determine any injuries within the skull, including any collections of fluid within the skull but outside the brain parenchyma, bleeding within the brain parenchyma, contusions, shear injuries, and brain swelling or edema.
Figure eight demonstrates four different cases that show subdural hemorrhages, which also means a collection of blood outside the brain. This is commonly caused by severe head injuries. These images are produced using radio waves and a magnet to generate images that get projected onto a computer. Movement affects the quality of the images so it is very critical that throughout the scan the patient needs to stay absolutely still or there is the chance of a repeat. To do this, restraining devices may be used to strap the patient down or using a sedative, also known as sleepy medicine, which can be used to relax the patient. Figure 8 Subdural Hemorrhage.
There are many advantages of MRI over the other imaging modalities. MRI has an increased contrast resolution that allows visual impact of an MRI scan to lead to greater indications of the findings of abuse in a courtroom setting. As shown in figure 9, this type of imaging device does not use ionizing radiation; it used magnets and gradient coils to collect the images needed. This makes MRI especially inviting for repeated examinations of the brain and for use in children. MRI also uses a special type of imaging called multiplanar imaging. This type of imaging altars the magnetic field allowing images to be obtained in multiple planes of view without repositioning the patient.Figure 9. MRI scanner.
Children of all ages can become victims of abuse and neglect. Abuse does not come in one form but comes in different forms of physical, emotional, and/or sexual abuse. This can be seen between direct and non-direct contact that affects the children in different aspects. Diagnostic imaging in child abuse plays an important role in the representation of skeletal injuries, soft tissue injuries, and brain injuries. The use of imaging modalities like diagnostic x-ray, computed tomography, and magnetic resonance imaging allows specific fractures and specific injuries to be detected depending on the exam. These modalities the ability to detect the first indications of child abuse. Each specific modality had advantages that help detect injuries that other modalities could not. It is very important to include imaging modalities when child abuse has been suspected.
