To save a life: How to recognize signs of child abuse

April’s Child Abuse Prevention Month is almost over, but that doesn’t mean efforts to stamp out child abuse should end.

Nurse Erika G. Janes is the Injury Prevention Coordinator for Safe Kids Louisville and Prevention & Wellness at Norton Children’s Hospital. She came to speak to law enforcement, social services and others in the community interested in preventing and recognizing signs of abuse in the children they serve.

“I was going to say, ‘Glad tidings,’ but if any of you have read the Child Maltreatment 2017 Report, you’ll know it’s not a very good thing,” said Janes.

Kentucky, she said, is once again the state with the highest child abuse rate in the country.

“If you can picture an entire classroom of children hurt for every two schools of elementary children, that’s what happens in Kentucky,” she said.

Indiana isn’t much better. Janes said it came in second place, with 19 kids hurt for every 1,000 children. Both rates are double the national average. However, while child-abuse-related deaths in Kentucky have gone down, the death toll in Indiana has gone up for the third straight years. Nearly 40 children died in 2017.

“We can sit here and be horrified, but Child Abuse Prevention Month won’t let us do that,” said Janes. “We’d all give up. We can’t do that.”

Janes’s purpose in coming to speak here in Washington County was to outline, once again, the early signs of child abuse so intervention can happen before it’s too late.

“It’s very rare for a child to die the first time they are mistreated or neglected,” said Janes. “Very rare. It is often the culmination of escalating violence against the child. All of us are in a position … through our neighborhoods and our families to help these kids.”

Janes showed a graph of the people who typically call in to report abuse. Nearly 20 percent were teachers, another 20 percent were law eforcement and just more than 10 percent were social workers. Less than 14 percent were parents or relatives who had not committed the abuse and only 4 percent were neighbors, all people who had much more access to a child than teachers, law enforcement or social workers. Anonymous sources and the ambiguous “other” categories were higher than parents, relatives and neighbors.

“The professionals do it — the educators do it, social workers do it, nurses do it,” said Janes. “Not very much, but none of the neighbors or family members do it very often and that has got to change. If we are going to get to these kids early, we have got to get people to call in, known or suspected abuse … You don’t need all the pieces of the puzzle. If you know in your gut something is wrong or going on, you need to call.”

When it comes to infants, one of the most common forms of abuse is being shaken. Infants have more space between the outside of the brain and inside of the skull and have a large head-to-body ratio and weak neck muscles. The infant brain is also 25 percent more water than an adult’s brain.

“Think under-set gelatin,” read one of Janes’s slides.

This all adds up to a significantly higher risk of a subdermal hematoma, a collection of blood outside the brain, which can sometimes be life-threatening, even for adults.

“This is what they say happened to the baby, trying to get off if they’ve been charged with abuse,” said Janes. “It was a fall. It was the dog that caused it. It was another immunization. Vitamin deficiency. The toddler did it. … If there’s bleeding on the brain, we know something has happened to this child.”

She quoted a statement made in the 2001 AAP Committee on Child Abuse and Neglect report: “The act of shaking leading to shaken baby syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child.”

“Now, I ask you, have you ever been to the store and seen somebody in the checkout lane with a bunch of little kids and the adult just loses it and swats a bottom?” Janes asked. “You might have done it. But have you ever seen someone pushing a baby in the cart and the baby is just crying and crying and the adult unbuckles the baby and just shakes the heck out of them? No, because they do it in private. They know not to do that. It is rare that someone accidently shakes that baby … We have to teach people other ways to calm infants.”

She showed an illustration and an X-ray of a child’s knee with “bucket-handle fractures,” another injury she said is extremely rare in accidental situations.

“Maybe you have a toddler and you’re trying to change a diaper and, bless his soul, there’s nothing faster than a naked baby,” she said. “You take that diaper off and that baby rolls over and off they go. That’s the last thing you needed that day so you grab their leg and yank them back and it’s a shearing injury. This is not a fall, this is not a twist; this is a shearing, intentional injury.”

Due to the cartilaginous state of infant bones, signs they’ve been broken aren’t always immediately apparent. Jane said after taking initial X-rays, doctors will ask parents to bring the child back in 10 to 14 days for another X-ray. If the bones have been broken, there will often be build-ups of calcium trying to repair the breaks.

The most overlooked sign of abuse, she said, is something most children get fairly often — bruises. Janes showed a slideshow of bruises that should be suspect when individuals see them on children. She highlighted the TEN-4 rule. Bruising on the torso, ears, or neck of a child younger than 4 years of age or any bruising on a child 4 months old or younger indicates something may be wrong.

“If a child isn’t cruising [pulling up on things and trying to take steps], they shouldn’t be bruising,” said Janes.

The slide she showed had a picture of a small child’s bare bottom with a hand-sized bruise and clear handprint.

“That wasn’t a spanking,” said Janes. “That was a whooping. It is legal in all 50 states to spank a child, but you cannot leave an injury. This is an injury.”

Torso bruises come in all sizes and may be along the ribs, front or back, from being shaken, or could be larger from being hit or kicked. Bruising on the ear could be from being grabbed or, in the case of Janes’s slides, an infant being kicked in the head. Bruising on the neck and chin could be from being strangled or shaken. The child’s chin could have hit the collarbone hard enough to bruise it and in some cases, bruising at the back lower neck could be caused by the back of the head hitting the back of the neck.

Janes reminded those there for the seminar that the person bringing the child to the emergency room could have no knowledge of what’s been done to the child. However, partners tend to protect each other as well.

“You just never know,” she said.

She told another story illustrated by pictures. After a man lost his job, his girlfriend had to go to work, leaving the baby, who wasn’t his child (“That matters,” Janes said) home with him. When the mother got home, she went to give the baby a bath and found a small bruise on the baby’s belly. She touched it and the baby giggled, but she still didn’t feel right about it, so she took the baby to the doctor. The doctor sent the baby to the hospital immediately, where it was found the baby had a grade 3 liver laceration.

“If the mom hadn’t followed up on that bruise and if the doctor didn’t have the training, where was that baby going to be the next day?” asked Janes. “Probably dead.”

Janes said parents must be careful who children are left with. Research shows that fathers are most often the abuser, followed by the mother’s boyfriend, then the mother and then a female babysitter.

Janes said in cases of domestic violence she’s heard from many women who tell her they stay so he won’t hurt the kids.

“This picture is proof — if you’re on a power trip, you’ll hurt anything that’s in that room,” she said. “The neighbors had quit calling the police because every time the police came, they said, ‘We’re sorry officer; we won’t do it anymore,’ but this time, the neighbor said he heard a baby cry in a way he’d never heard a baby cry before and so he sent not only the police, but social workers to do a welfare check.”

They found the baby in the crib, covered from top to bottom in bruises. The mother claimed the baby was in a new sleeper and caused a rash. The social worker didn’t fall for that and got the baby to the hospital, where he was saved.

“Who saved that baby’s life?” Janes asked. “It was the neighbor.” She said nowadays, people are reluctant to get involved in their neighbor’s business. “But you can do this anonymously. You can call and be anonymous, but we’ve got to make the call.”

She said she was with a group passing out bike helmets in Bowling Green, Kentucky, and a boy came up to her with a blackened, bruised ear. She said she had no pen or paper to write names, phone numbers or addresses, so she didn’t have a way to report the child to the authorities.

“He’s still in Bowling Green; I have no idea how he’s doing,” she said. “I went around asking people what I could do. I don’t know if someone had boxed his ears or what they did, but that boy had been hurt. That boy stays with me every day of my life.”

Janes acknowledged the drug problem, both in Indiana and Kentucky, and its impact on the safety of children.

“We know that doesn’t help situations,” she said. “… We just chip away what we can every day when we go to work. Thank you for what you do, keep up the good work and … there will be happy childhoods, by golly.”