Opinion Article
When a Child's Life Depends on Us Recognizing Cutaneous Signs of Child Abuse
Cuando la vida de un niño depende de que sepamos reconocer los signos cutáneos de maltrato
Servicio de Dermatología, Hospital Infantil del Niño Jesús, Madrid, Spain
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Hernández-Martín, A. Torrelo" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Hernández-Martín" "email" => array:1 [ 0 => "ahernandez_hnj@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Torrelo" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Dermatología, Hospital Infantil del Niño Jesús, Madrid, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cuando la vida de un niño depende de que sepamos reconocer los signos cutáneos de maltrato" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Abuse is the worst possible attack on a child's dignity and wellbeing, and the law protects children against any type of physical or psychological assault. In 1959, just over a century after Charles Dickens had denounced the vulnerability of children in <span class="elsevierStyleItalic">Oliver Twist</span>, the United Nations General Assembly adopted the Declaration of the Rights of a Child, considered to be the first legal manifesto for the protection of minors. In 1962, an article published by Kempe et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> on battered child syndrome profoundly changed how the victims of child abuse were cared for and raised public awareness, prompting the adoption of legal measures that directly affected children. In Spain, in addition to the legislation in different autonomous communities, the Organic Law 1/1996 for the Legal Protection of Minors, dated January 15, requires physicians to protect the physical and psychological integrity of children and to report any suspected assault, past or present.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although it is beyond question that child abuse occurs, exact figures for its incidence in Spain are lacking. We do know that the number of reports is increasing, but it is difficult to count exactly how many cases there are because the physician involved may not know the procedure for filing the report, be worried about being wrong, or lack conclusive evidence of the cause of the lesions. In addition, some cases that are detected may go unreported because of the great shame associated with the problem. Finally, the paperwork for reporting child abuse varies in each autonomous community and differences in classification, collection, and processing of data make it hard to produce reliable national statistics.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Skin lesions are present in 90% of child abuse cases, but dermatologists are rarely consulted to assess these lesions, probably because pediatricians expert in child abuse can recognize them readily. However, assessment of such lesions on a child when there is a suspicion of abuse may not be easy for a number of reasons. First, it can be difficult to recognize the signs of abuse. These can be very subtle when the abuse is continuous and longstanding. Moreover, the morphology and site of many different skin complaints can resemble abuse in an unabused child. The differential diagnosis includes a long list of conditions<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> encompassing normal variants and relatively common diseases, such as genital forms of lichen sclerosus et atrophicus, molluscum contagiosum in the genitocrural folds, acute hemorrhagic edema of infancy, bullous impetigo, and ulcus vulvae acutum or Lipschütz ulcer. To untrained eyes, these may resemble sexual abuse, malicious blows, or deliberate burns. Second, sensitivity is required when questioning the child's parents or caretakers. The physician may be uncomfortable asking difficult questions that may irritate or frighten those responsible for the child. The situation is further complicated because the appearance of the parents or caretakers of the child often does not provide any clues that might arouse suspicion of child abuse. Third, it may be that the actual abusers are not the parents but someone else in the family or social circle. Thus, a suggestion of possible abuse may cause alarm, arouse suspicions, and have serious repercussions on family relationships. Fourth and last, when no other signs are present, clinicians often tend to unconsciously dismiss the suspicion of abuse because it is hard, if not impossible, to understand why anybody could behave so cruelly toward a child.</p><p id="par0020" class="elsevierStylePara elsevierViewall">While the lesions reviewed in this issue of the journal may unequivocally point to abuse, we should also be aware of the lesions inflicted as a result of cultural customs, religious rites, or nutritional obsessions. Although these lesions are not intentional, the parents are not absolved of guilt and we cannot quietly ignore their presence. For example, ritual incisions, the application of very hot substances as a cure, or diets followed by strict vegetarians or vegans may lead to the appearance of permanent scars from wounds or burns, and deficiencies that endanger the child's wellbeing.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Since as dermatologists we are obliged to safeguard the health of the child, the question that arises is whether it is our duty to report our suspicions to the appropriate authorities or whether an explanation of the origin of the lesions to the parents and subsequent follow-up on our part is an acceptable course of action.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Undoubtedly, any assessment of a child suspected of being abused should be multidisciplinary. The collaboration of pediatricians, specialists, social workers, and psychologists with experience in abuse will help us confirm our suspicions and allow the appropriate professionals to follow-up with the patients and their families. When there are solid grounds for suspicion, the competent legal body should be informed, usually the examining magistrate and public prosecutor responsible for minors. The process can be initiated even in the absence of complete certainty because the life of a child may be in danger. In any case, it is not the task of a physician to accuse anyone of abuse, but rather to ask the competent authorities to investigate the case. The case should also be reported anonymously to the corresponding register of the autonomous community to provide data for statistical analyses that will help instate programs aimed at detecting and preventing child abuse as well as providing information and support for the victims and the public in general.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Early detection is important to protect the child from further physical or psychological harm. Studies have shown the relationship between physical abuse and psychological disorders, with high rates of depression, anxiety, and a predisposition to drug abuse in abused patients.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, while it is our obligation to report any solid suspicion of abuse, to do so without good evidence could be very harmful for the child and the whole family. A failure to do our duty could cost the life of the child while an overzealous approach could destroy the reputation of an innocent person.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The author declares no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Hernández-Martín A, Torrelo A. Cuando la vida de un niño depende de que sepamos reconocer los signos cutáneos del maltrato. Actas Dermosifiliogr. 2012;03:90–1.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The battered-child syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.H. Kempe" 1 => "F.N. Silverman" 2 => "B.F. Steele" 3 => "W. Droegemueller" 4 => "H.K. 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| 2020 July | 27 | 19 | 46 |
| 2020 June | 38 | 29 | 67 |
| 2020 May | 24 | 21 | 45 |
| 2020 April | 31 | 17 | 48 |
| 2020 March | 39 | 15 | 54 |
| 2020 February | 7 | 2 | 9 |
| 2020 January | 0 | 2 | 2 |
| 2019 December | 4 | 2 | 6 |
| 2019 November | 0 | 1 | 1 |
| 2019 October | 0 | 2 | 2 |
| 2019 September | 4 | 2 | 6 |
| 2019 June | 1 | 2 | 3 |
| 2019 May | 1 | 11 | 12 |
| 2019 April | 0 | 1 | 1 |
| 2019 March | 2 | 9 | 11 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 6 | 0 | 6 |
| 2018 February | 27 | 2 | 29 |
| 2018 January | 42 | 7 | 49 |
| 2017 December | 40 | 7 | 47 |
| 2017 November | 31 | 3 | 34 |
| 2017 October | 42 | 5 | 47 |
| 2017 September | 30 | 2 | 32 |
| 2017 August | 48 | 6 | 54 |
| 2017 July | 39 | 7 | 46 |
| 2017 June | 36 | 6 | 42 |
| 2017 May | 43 | 6 | 49 |
| 2017 April | 23 | 5 | 28 |
| 2017 March | 23 | 10 | 33 |
| 2017 February | 20 | 5 | 25 |
| 2017 January | 22 | 6 | 28 |
| 2016 December | 45 | 19 | 64 |
| 2016 November | 57 | 5 | 62 |
| 2016 October | 54 | 16 | 70 |
| 2016 September | 47 | 3 | 50 |
| 2016 August | 58 | 11 | 69 |
| 2016 July | 46 | 5 | 51 |
| 2016 June | 8 | 4 | 12 |
| 2016 May | 5 | 0 | 5 |
| 2016 April | 6 | 1 | 7 |
| 2016 March | 8 | 0 | 8 |
| 2016 February | 12 | 5 | 17 |
| 2016 January | 10 | 0 | 10 |
| 2015 December | 13 | 2 | 15 |
| 2015 November | 15 | 1 | 16 |
| 2015 October | 16 | 3 | 19 |
| 2015 September | 5 | 5 | 10 |
| 2015 August | 9 | 4 | 13 |
| 2015 July | 45 | 5 | 50 |
| 2015 June | 42 | 8 | 50 |
| 2015 May | 80 | 6 | 86 |
| 2015 April | 49 | 6 | 55 |
| 2015 March | 35 | 6 | 41 |
| 2015 February | 32 | 10 | 42 |
| 2015 January | 50 | 10 | 60 |
| 2014 December | 32 | 11 | 43 |
| 2014 November | 26 | 11 | 37 |
| 2014 October | 46 | 17 | 63 |
| 2014 September | 42 | 13 | 55 |
| 2014 August | 51 | 14 | 65 |
| 2014 July | 55 | 18 | 73 |
| 2014 June | 76 | 10 | 86 |
| 2014 May | 75 | 10 | 85 |
| 2014 April | 51 | 5 | 56 |
| 2014 March | 64 | 22 | 86 |
| 2014 February | 16 | 6 | 22 |
| 2014 January | 18 | 3 | 21 |
| 2013 December | 28 | 9 | 37 |
| 2013 November | 23 | 6 | 29 |
| 2013 October | 14 | 7 | 21 |
| 2013 September | 19 | 5 | 24 |
| 2013 August | 9 | 8 | 17 |
| 2013 July | 8 | 8 | 16 |
| 2013 June | 8 | 12 | 20 |
| 2013 May | 11 | 11 | 22 |
| 2013 April | 5 | 14 | 19 |
| 2013 March | 19 | 5 | 24 |
| 2013 February | 29 | 5 | 34 |
| 2013 January | 6 | 2 | 8 |
| 2012 December | 13 | 3 | 16 |
| 2012 November | 2 | 0 | 2 |
| 2012 October | 1 | 0 | 1 |
| 2012 September | 1 | 0 | 1 |
Show all
