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Child abuse results not only from physical abuse but emotional and/or sexual abuse. Effective diagnostic imaging of child abuse is based on high quality technology as well as a full appreciation of the clinical and pathologic modifications occurring in abused children. The main goal of diagnostic imaging is to find and identify the degree of the physical injuries when abuse is present by using these advanced modalities and to clarify all imaging discoveries that point to alternative findings.
Child abuse can be physical, emotional, and/or sexual.
Abuse mainly comes from contact but it can also result from 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 possibly even death.
Diagnostic imaging plays an important role in child abuse because often the history provided is either incomplete or can show misleading results. The information given in these types of imaging provide high quality images obtained by trained technologists.
Diagnostic imaging not only helps to identify the extent of injuries, but it also can show any medical diagnoses when abuse is not present.
In the United States, more than 4 children die from child abuse and neglect on a daily basis. Over 70% of these children are below the age of 3(11). Abused children encompass more than bruises and broken bones. Even though physical abuse can seen by the eye, other types of abuse such as emotional and sexual abuse, also leave deep, lasting scars on children.
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 an alternative diagnoses if needed. 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 transpire in any cultural, ethnic, or income group1. Child abuse can be physical, emotional, and/or sexual. Abuse mainly comes from contact but it can also result from 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 possibly even death.
When people think of child abuse, their first thing that comes to mind is physical abuse. Physical child abuse is one of the most common forms of abuse. this type of abuse is a non-accidental act that results in physical injury inflicted upon the child with cruel and/or malicious intent6. This frequently happens when a person is either angry or frustrated causing them to beat, shake, or throw a child. Figure 1 shows 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 child abuse as well. It’s the leading cause of death in child abuse cases in the U.S(12) In most incidents, all it takes is just a few seconds of abuse to cause brain damage or even cause death to the child. Figure 1. A child who has been a victim of physical child abuse.
Emotional abuse is one of the hardest forms of abuse to identify. It can be subtle and manipulative, but more importantly it can be dangerous. Emotional abuse in children is an often 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(13). This type of abuse is a display of behavior that also can damage a child’s self esteem and/or sense of self-value. This type of abuse is a way to control, in the same way that physical abuse controls another 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 choice7. Emotional child abuse can occur in several different forms. In some cases, it involves threatening, insulting and/or belittling words or actions to the child, or it can result in a disorder called emotional deprivation. This type of abuse can often occur in affiliation with other types of abuses like, physical, sexual abuse or even 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.
Lastly, sexual abuse is another form of abuse that can cause harm to the child. A child is sexually abused when they are forced or persuaded to take part in sexual activities(14). This type of abuse does not only just occur physically, but also it can occur online. Contact abuse occurs when the child becomes in contact with the abuser, including penetration. This includes, but is not limited to, touching any part of the body sexually whether the child’s wearing clothes or not, 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 abuse images, showing pornography to a child, and/or sexually exploiting a child for money, power or status. These acts of abuse are carried out by many types of offenders, including trusted friends or family, men or women, or even strangers.
The first step in helping a child is recognizing the signs and symptoms of child abuse. It is not always easy to take notice if the child has been abused because the child may feel guilty, ashamed or even confused about what has happened. The child may be afraid to speak about the abuse; especially if the abuser is someone they know like a parent, a relative or family friend. Specific signs and symptoms depend on the type of abuse and can vary.
Physical child abuse ranges from unexplained injuries, such as bruises, fractures or burns to Injuries that don’t match the given explanation. Emotional child abuse signs/symptoms 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/symptoms of sexual child abuse are any genital pain or bleeding, blood in the child’s underwear, abdominal pain, unusual fear or any sexual transmitted diseases.
A combination of individual, family, and/or community factors contributes to the risk of a child being abused. Although children are not responsible for the harm inflicted upon them, certain characteristics have been found to increase their risk of being abused8. Risk factors may not be direct causes but are those characteristics associated with child abuse itself. The individual risk factors affect children who are under the age of 4 and those who have special need like disabilities, and mental health issues. Family risk factors affect children in social isolation, negative interactions, and family violence. Lastly, community risk factors affect children who live in a concentrated neighborhood disadvantage like high poverty, high unemployment rates, and high quantity of alcohol use.
The treatment of child abuse can be helpful for both the parents and the child. If there is any suspicion that the child has been abused ensuring the child’s safety is the first priority. Seeking medical attention is the next step to check for injuries that can be critical. The child can develop physiological problems that can affect the child’s behavior, relationships, etc. Talking to a mental health professional can help a child to be able to trust again, teach a child conflict management and how to boost their self-esteem, and lastly teaching a child what a normal behavior is and how relationships should be formed.
Diagnostic imaging plays an important role in child abuse because often the history provided is either incomplete or can show misleading results and the physical examination doesn’t always show injuries that can be involved in abuse cases. With diagnostic imaging, it 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 trained technologists. Diagnostic imaging not only helps to identify the extent of injuries, but it also can show any medical diagnoses when abuse is not present.
A diagnostic X ray is the method of choice for imaging in cases of suspected child abuse. 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. The images can reveal signs of disease and injury10. X-rays are a quick and painless exam and is demonstrated in figure 2. When the X-ray beams passes through the body, they get absorbed depending on the density of the material they pass through. The dense materials, such as bone and metal, show up as white on X-rays and the air in your lungs shows up as black.
X-rays are very low radiation doses that are absorbed during imaging procedures. They commonly produce no adverse effects, but it is still very important to reduce the dose as much reasonably achievable and use the appropriate shielding to protect the children from radiation. For example, the radiation dose absorbed from an X-ray examination such as a chest X-ray or a skull X-ray is moderately lower than what is received annually from natural sources.
If the child is suspected to have gone through physical abuse, a skeletal survey, as shown in figure 3, is the first step in the imaging process to focus in on the entire bony skeleton. In other words, it is a series of x-rays that take images of all the bones in the body. A skeletal survey is very important in the cases with children less than 2 years old. In children older than 5 years, a skeletal survey is unfortunately little value in screening for injuries2. Skeletal surveys can help to identify distinctive injuries such as the metaphyseal lesion in the long bones or posterior rib fractures, both of which are highly suggestive of physical abuse even when medical information is lacking or misleading. To acquire the best images, the skeletal survey is performed at the finest level using high detail imaging systems. The images acquired follow a protocol with directions for positioning the patient (which essentially could require restraining devices) and proper centering/coning of images to the appropriate body parts needed (with shielding of others). This will ensure the images provide the essential detail to view subtle skeletal injuries while keeping the patient radiation dose as low as reasonably achievable.[image: ]Figure 3. Skeletal survey done on children if abuse is suspected.
A CT scan, as shown in figure 4, combines both the X-ray images taken from different angles around your body and uses a computer to create cross-sectional images of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than diagnostic X-rays do9. This type of imaging is quick, painless, and accurate. In emergency situations, A CT scan can reveal internal bleeding and injuries fast enough to help save lives.[image: ]Figure 4. Children friendly CT scanner.
Although CT scans do expose more radiation than diagnostic X-rays, there are still very few risks associated with this type of scan. One of the main risks to is having an allergic reaction to the contrast agent. For the most part, the reaction is mild which can lead to itchiness or a rash but in very few cases, the contrast can produce a life-threatening reaction. In children, ionizing radiation may be more harmful because they are still growing and have more years to be exposed to radiation.
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 abuse2. In addition, abusive head trauma is one of the main leading causes of death in children under the age of 2 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 abnormalities3. Shown to the right in figure 5 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 scalp11. Most injuries caused by child abuse are easily found during these imaging studies. Acute cerebral injury in a victim of child abuse.
There are many advantages associated with computed tomography. With speed, this scan can be as short as 5 to 15 minutes, in comparison to 30 minutes for an MRI scan. CT is also more readily available than MRI because of the quick scanning that can be done and the cost of a CT scan is approximately two-thirds less than the cost of an MRI scan. 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 brain2.
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 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 scanner6. 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.
An MRI scan is a painless scan that has the advantage of no x-ray radiation exposure. With that, there are no known side effects of an MRI scan. Patients who have any metallic materials within the body must inform the MRI staff because any metal in the body can significantly distort the images obtained by the MRI scanner. Patients who have certain types of metals like pacemakers, metal implants, or metal chips/clips in or around the eyes would not be able to get an MRI scan due to the risk of the magnet causing the metal to move during the scan.
MRI scans are part of the imaging process when typical skeletal injuries associated with shaking or impact on the child are identified. MRI have the highest sensitivity and specificity for diagnosing sub acute and chronic injury4 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.
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 7, 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 allows images to be obtained in multiple planes of view without repositioning the patient.
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 occurred in the absence of signs of external head trauma2. This occurs when the baby violently gets shaken repeatedly which can cause brain swelling, internal bleeding, mental retardation, or even death. Babies have very weak neck muscles that cannot fully support their heads. As shown in figure 8, severe shaking causes the baby’s head to move violently back and forth and forces can be exaggerated if the shaking is interrupted by the baby’s head hitting a hard surface.[image: ]Figure 8. Shaken Baby Syndrome
Diagnostic imaging in child abuse plays an important role in the representation of skeletal injuries, soft tissue injuries, and brain injuries. The use of correct imaging modalities like diagnostic X-ray, CT, and MRI allows specific fractures and specific injuries to be detected depending on the exam. The have the ability to detect the first indications of child abuse. Each specific modality had advantages that helped detect injuries that other modalities could not. It is very important to include imaging modalities when child abuse has been suspected.
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