GC143 A Child With Multiple Bruises: Child Abuse
Child abuse is the intentional infliction of physical, emotional, or sexual harm on a child by a caregiver, often presenting with multiple bruises in various stages of healing at unusual locations inconsistent with the child's developmental stage.
This lecture addresses one of the most clinically and ethically important topics in paediatrics: recognizing, diagnosing, and managing child abuse. The lecture is delivered by Dr. Maria NW Wong (Department of Paediatrics & Adolescent Medicine, HKU/QMH) and was built around the then-current Procedures for Handling Child Abuse (Revised 2015). For present practice, use the SWD's Protecting Children from Maltreatment — Procedural Guide for Multi-disciplinary Co-operation (Revised 2026) and the Mandatory Reporting of Child Abuse Ordinance, which commenced on 20 January 2026. [1][8][9]
The overarching message is deceptively simple but profound:
"If you don't think about it, you won't diagnose it." [1]
Recognition requires suspicion first, followed by careful history, examination, investigation, and multidisciplinary synthesis. Record each account accurately and assess whether it fits the child's development and the injuries; do not assume that a particular caregiver is the perpetrator or that demeanour proves or disproves maltreatment.
Learning Objectives (from the lecture) [1][2]
- Recognize the different types of child abuse and their physical signs
- Differentiate between accidental and non-accidental injuries (NAI)
- Understand the long-term adverse effects of child abuse and the importance of child protection
- Understand the multidisciplinary approach to management
"All children have the right to be protected against harm and exploitation. The safety, needs, welfare and rights of the children should always come first." [1]
These are legal and procedural cornerstones. In Hong Kong, the current framework is the SWD's Protecting Children from Maltreatment — Procedural Guide for Multi-disciplinary Co-operation (Revised 2026). It coordinates health care, social welfare, education and law-enforcement responses. [8]
Why this matters clinically: share the information necessary to protect the child through the current safeguarding pathway, with need-to-know proportionality and careful documentation. Since 20 January 2026, specified professionals in 25 categories have a statutory duty to report as soon as practicable when, in the course of work, they have reasonable grounds to suspect that a child is suffering serious harm or is at real risk of serious harm. [8][9] If danger is immediate, stabilize the child and activate emergency safeguarding procedures without delay.
Child abuse is defined as any act of commission or omission that endangers or impairs the physical/psychological health and development of an individual under the age of 18. [1]
Key conceptual breakdown:
- Commission = doing something harmful (hitting, burning, sexual contact)
- Omission = failing to do something necessary (not feeding, not providing medical care, not supervising)
- Judged on the basis of a combination of community standards and professional expertise — this means cultural context matters but does not excuse harm [1]
| Type | Key Features |
|---|---|
| Physical abuse | Non-accidental use of force, deliberate poisoning, suffocation or burning [1] |
| Sexual abuse | Involvement of child in sexual activities they cannot understand/consent to; includes contact and non-contact activities [1] |
| Neglect | Severe or repeated pattern of lacking attention to basic needs (physical, medical, educational, emotional) [1] |
| Psychological abuse | Acts that damage behavioural, cognitive, affective, or physical functioning: spurning, terrorizing, isolating, exploiting/corrupting, denying emotional responsiveness [1] |
| Mixed/Multiple abuses | Combination of the above [1] |
Exam Tip
The lecture emphasizes that physical abuse is commonly tested. Its statement that neglect made up 75% of cases in children under 2 is historical slide data, not a current prevalence estimate. Know all maltreatment types and avoid using prevalence to rule a case in or out. [1]
The lecture categorizes risk factors into three domains [1]:
| Domain | Risk Factors |
|---|---|
| Family | Social isolation; crisis/tension (pregnancy, divorce, in-law conflict); cultural/superstitious beliefs; domestic violence (spouse battering) |
| Parents | History of childhood abuse; psychiatric disorder; alcoholism/drug abuse/gambling; rigid/unreasonable expectations; belief in corporal punishment; immature parents; poor impulse/anger control; poor parenting skills |
| Child / care demands | Feeding or sleeping difficulties; early separation from caregivers; conflicting caregiving practices; disability or chronic illness; the child being blamed for family misfortune |
Why understanding risk factors matters: these are population-level vulnerabilities, not diagnostic features. They should prompt offers of support and attentive assessment, not profiling. Poverty, single parenthood, disability, substance use or psychiatric illness never substitutes for evidence about the child's safety and clinical findings.
5. Adverse Childhood Experiences (ACE) & Neurodevelopmental Impact
As the number of ACE increases, the risk for health problems increases.
The ACE pyramid illustrates a whole-life progression [1]:
- Adverse Childhood Experiences (base)
- Social, Emotional, & Cognitive Impairment
- Adoption of Health-risk Behaviours
- Disease, Disability, and Social Problems
- Early Death (apex)
ACE categories include:
- Childhood maltreatment (abuse & neglect)
- Household dysfunction (spouse abuse, substance abuse, mental illness, separation/divorce, incarceration)
Long-term health consequences of ACE [1]:
- Alcoholism, substance abuse, smoking
- Depression, suicide attempts
- Ischaemic heart disease, COPD, liver disease
- Multiple sexual partners, STDs, unintentional pregnancies
This section of the lecture draws from the Harvard Center on the Developing Child:
- Early experiences influence the developing brain
- Plasticity is greatest in the first years of life and decreases with age
Neural connections for different functions develop sequentially [1]:
- Sensory pathways (vision, hearing) — develop earliest, peak in early infancy
- Language — rises after sensory pathways, peaks during infancy
- Higher cognitive function — develops latest, peaks in later childhood/adolescence
As circuits mature, unused connections are eliminated through pruning, making the remaining circuits more efficient. [1]
- In the first few years of life, more than 1 million new neural connections are formed every second
- Normal brain development depends on "serve and return" interactions — responsive caregiving shapes brain circuitry
- Brains subjected to toxic stress have underdeveloped neural connections in areas most important for successful learning and behaviour
The affected brain regions include the prefrontal cortex and hippocampus — areas critical for executive function, learning, and memory. [1]
| Type | Description | Effect |
|---|---|---|
| Positive stress | Brief, mild stress responses (e.g. first day of school) | Normal, builds resilience |
| Tolerable stress | More severe but buffered by supportive adult relationships | Recoverable |
| Toxic stress | Strong, frequent, prolonged activation without buffering | Weakens developing brain architecture, lifelong problems in learning, behaviour, physical and mental health |
Dose-response relationship [1]:
- As the number of risk factors increases from 1–2 to 7, the percentage of children with developmental delays rises from ~10% to nearly 100%
- ACE also predicts adult disease: the odds ratio for adult ischaemic heart disease rises from 1.0 (0 ACE) to ~3.2 (7–8 ACE)
High Yield for Exam
The concept of toxic stress and its effect on brain architecture is a favourite exam topic. Know that the key protective factor is a stable, supportive adult relationship — this is the best way to prevent adverse effects of ACE. [1]
The Harvard Center on the Developing Child identifies three principles to improve outcomes for children and families [1]:
- Support responsive relationships (stable caregiving)
- Reduce sources of stress (address material and psychosocial stressors)
- Strengthen core life skills (executive function, self-regulation, planning)
These three principles operate in a reinforcing cycle and lead to healthy development & educational achievement in children and responsive caregiving & economic stability in adults. [1]
The Triad [1]
Suspicion → History → Investigation"If you don't think about it, you won't diagnose it." [1]
7. Physical Abuse — In Detail
A physical injury or physical suffering to a child, including non-accidental use of force, deliberate poisoning, suffocation, burning, and Medical Child Abuse (Munchausen Syndrome by Proxy).
- Severe life-threatening injuries
- Delay in seeking medical help in less severe injuries
- Bruises or minor injuries noticed by teachers or nursery staff
- Discovered on routine medical check-up
| Rank | Injury Type | Notes |
|---|---|---|
| 1 | Superficial injuries/bruises | Most common |
| 2 | Bone fractures | Second most common |
| 3 | Burn or scald | |
| 4 | Intracranial injuries | Most common cause of child abuse DEATH |
| 5 | Injuries to mouth | |
| 6 | Visceral injuries | Second most common cause of death (reported case fatality 40–50%) |
| 7 | Suffocation |
History is very important.
Features suggestive of abuse [1]:
| Feature | Why It's Suspicious |
|---|---|
| Injuries not consistent with history or developmental age of child | A 3-month-old cannot roll off a bed and fracture a femur |
| Unexplained or poorly explained injuries | Vague accounts like "I don't know what happened" |
| Inconsistent history between caregivers | Father says child fell; mother says child was hit by sibling |
| Changing history | Story changes each time you ask |
| Delay in seeking help | A parent who waits 2 days to bring a child with a fracture |
| Account remains incompatible after careful clarification | Record the caregiver's words and observed behaviour, but do not treat anxiety, anger or defensiveness alone as evidence of abuse |
8. Superficial Injuries / Bruises
- Concerning sites include ears, neck, cheeks, torso/abdomen, buttocks, genitalia and protected soft surfaces such as inner arms or thighs
- Typical accidental bruises occur over bony prominences (forehead, shins, knees) in mobile children
Patterned injuries may carry a recognisable imprint, as illustrated by the lecture's montage of ear/neck/trunk bruises and implement-shaped marks. Patterns include [1]:
- Loop/linear marks — whips, cords, belts, clothes hangers, sticks
- Parallel linear marks — fork, hair brush
- Hand imprint / knuckle marks
- Bite marks — semicircular paired-arch pattern
- Circular burns — cigarettes/cigars, automobile cigarette lighter, light bulb
- Grid pattern — space heater grids
- Outline burns — clothes iron, curling iron
- Absorption of bruises depends on vascularity of affected tissue and extent of injury
Do not date a bruise from its colour — there is no reliable colour exception. [12]
Bruise colour varies with depth, site, tissue vascularity, lighting, observer and skin tone. The slide's statement that a yellow bruise can be dated to 18–24 hours is outdated and must not be used clinically or forensically. [12]
Infants who do not pull to standing seldom bruise. [1]
Bruising is uncommon in pre-mobile infants. Any unexplained bruise in a child who is not yet independently mobile warrants prompt, careful assessment for inflicted injury and medical mimics; it is concerning, but not by itself diagnostic. The classic memory aid is "Those who don't cruise, rarely bruise." [12]
Past Paper Alert
Past paper Q21 (Nov 2020 Fourth Summative MCQ): "Which of the following is a correct opinion regarding a bruise?" Correct answer: "Not all blunt force traumas result in a bruise." Colour does not date it, and size does not quantify force. A true imprint can be patterned, but most bruises cannot identify the exact implement. [4][5][12]
| Condition | Key Differentiating Feature |
|---|---|
| Bleeding tendency (ITP, haemophilia) | Check CBC + coagulation screen; pattern of bleeding (petechiae in ITP, deep-seated bleeding in haemophilia) |
| Henoch-Schönlein purpura (HSP) | Palpable purpura over buttocks/lower extremities + arthralgia ± abdominal pain ± nephritis |
| Congenital dermal melanocytosis | Stable blue-grey macules, often lumbosacral; document distribution and persistence so they are not repeatedly mistaken for bruises |
| Folk remedies: cupping (拔罐) and scraping (刮痧) | Characteristic circular marks (cupping) or linear marks (scraping) on back/limbs; cultural history |
Critical DDx
Evaluate bleeding disorders and safeguarding concerns in parallel. FBC and targeted coagulation testing can identify a medical contributor, but a bleeding disorder does not exclude coexisting inflicted injury. Avoid accusatory language and seek paediatric/haematology input when the pattern or results are unclear.
9. Fractures
- 80% of inflicted fractures are found in infants under 18 months (only 2% of accidental fractures occur in this age group)
- 43% of fractures are unsuspected clinically — found only on skeletal survey
These figures are useful for understanding why occult injury is actively sought in infants, but they are cohort-dependent rather than current universal probabilities.
- Not moving/using the limb
- Pain
- Swelling
- > 1 fracture
- Fractures in multiple sites
- Fractures in different stages of healing
- Presence of other injuries
- History of injury not plausible
Classic metaphyseal lesion (CML) / "bucket-handle fracture" Posterior rib fracture Scapular fracture Spinous process fracture Sternal fracture
| Fracture Type | Why It Suggests Abuse |
|---|---|
| CML / bucket-handle or corner appearance | The metaphyseal fragment is seen tangentially as a bucket handle or en face as a corner. It is highly associated with inflicted shearing injury, but diagnosis still requires the whole clinical and radiographic context |
| Posterior rib fracture | The lecture radiograph shows multiple posterior healing rib fractures. These strongly raise concern for chest compression in an infant, while birth injury, major trauma and bone fragility remain relevant differentials |
| Scapular fracture | Requires significant direct force; extremely rare in accidental injury |
| Spinous process fracture | Requires hyperflexion/direct blow; unusual mechanism for accident |
| Sternal fracture | Requires severe direct force to anterior chest |
Spiral fractures of the lower extremities in non-ambulatory children are extremely suspicious. [1]
Why: A spiral fracture requires a twisting force. A pre-walking infant cannot generate this force on their own. In an ambulatory toddler, a "toddler's fracture" (spiral fracture of the tibia) is a recognized accidental injury — context matters.
| Radiographic Finding | Estimated Age |
|---|---|
| No early callus formation | < 7–10 days |
| Soft callus visible | After 1st week to 3–4 weeks |
Radiographic healing ranges overlap and cannot precisely date a fracture. In a child 24 months or younger with concern for physical abuse, a complete skeletal survey is usually appropriate; targeted imaging may be selected for older children according to findings and specialist advice. Follow-up skeletal survey after about 10–14 days can reveal occult healing fractures. [11]
Why repeat? Early fractures may not be visible initially. By 2 weeks, periosteal reaction/callus formation becomes apparent, revealing fractures that were occult on initial imaging.
Bone scintigraphy is not a replacement for the standard skeletal survey. It may be a selective adjunct after discussion with paediatric radiology when suspicion remains and radiographs are equivocal or incomplete. [11]
- Skull X-ray (SXR)
- Chest X-ray (CXR)
- X-ray of all 4 limbs
- X-ray of spine
Features of Non-Accidental Burns [1]
| Feature | Why It's Suspicious |
|---|---|
| Cigarette burns (7–8mm diameter) | Uniform circular burns; accidental cigarette contact is usually a glancing injury (elongated, not perfectly circular) |
| Scalds/immersion injury | The slide quotes full-thickness injury at 60°C after 4–6 seconds; depth depends on temperature, duration, skin thickness and first aid, so do not use this as a forensic stopwatch |
| Burn of uniform thickness | Accidental splashes cause variable-depth burns |
| Clear demarcation line (glove or stocking pattern) | Indicates the child's hand or foot was held in hot water |
| Absence of splash marks | Accidental immersion produces splash marks; deliberate immersion does not |
| Doughnut pattern on buttocks | Central sparing where buttocks press against cooler bathtub base |
| Sparing of palms, soles, areas between toes, abdominal skin creases | These protected areas are spared in forced immersion because the child reflexively clenches/folds |
What the burn photograph is teaching: a sharply demarcated, uniform-depth immersion pattern with protected flexural creases contrasts with the irregular margins, variable depth and splash distribution expected from many accidental spills. No single pattern is pathognomonic; reconstruct the mechanism against the child's development and the scene history.
11. Abusive Head Trauma (AHT)
Abusive head trauma (AHT) is the current umbrella term for inflicted cranial or intracranial injury caused by blunt impact, violent shaking, or both. [10]
- Infants < 12 months old at greatest risk
- Injury inflicted by blunt force trauma, shaking, or a combination of forces
A constellation described in the lecture includes:
- Retinal haemorrhages (65–95%)
- Subdural haemorrhages and/or subarachnoid haemorrhages
- Cerebral oedema
- Little evidence of external cranial trauma
- Mechanisms can include angular acceleration/deceleration, impact, hypoxic-ischaemic injury and secondary cerebral swelling
- Trigger for shaking: crying [1]
- Perpetrators who confessed report multiple episodes of shaking over weeks to months [1]
- 91% of children developed symptoms immediately after injury [1]
- Head large in proportion to body size
- Weak neck muscles
- Fragile, underdeveloped brains
The infant's relatively large head, weak neck musculature and developing brain increase vulnerability to acceleration-deceleration and impact forces.
Interpret the constellation, not a triad
Subdural haemorrhage, retinal haemorrhage and encephalopathy/cerebral oedema are not a stand-alone diagnostic triad. AHT is diagnosed by integrating the history, developmental plausibility, full examination, neuroimaging, ophthalmic findings, skeletal survey, laboratory evaluation and alternative diagnoses in a multidisciplinary assessment. [10]
- The history may be absent, evolving or incompatible with the child's development or injuries
- Usually in < 3 years old (typically 1st year)
- Common symptoms: lethargy, irritability, impaired consciousness, vomiting, poor feeding, breathing difficulties, apnoea
- Seizures (40–70%)
- Retinal haemorrhages (65–95%)
- Bruises ± grip marks over upper arms/chest
- CT head: the lecture images show convexity and anterior interhemispheric subdural blood, including bilateral and heterogeneous collections; CT is central in acute unstable head injury.
- MRI: better delineates parenchymal, hypoxic-ischaemic and diffusion abnormalities and may clarify extra-axial collections.
- Do not precisely date a subdural collection from CT density alone. Heterogeneous or differing densities can reflect sedimentation, rebleeding, cerebrospinal-fluid admixture or other processes; they do not by themselves prove separate episodes. [10]
The slides show extensive retinal haemorrhages, including multilayer and peripapillary changes. Numerous haemorrhages extending toward the retinal periphery, retinal folds or retinoschisis are strongly associated with severe trauma and particularly AHT, but no retinal finding is independently pathognomonic or able to date the event precisely. Examination should be by an experienced ophthalmologist and interpreted with the complete case. [10]
The percentages below are historical figures quoted by the lecture and vary by cohort; the enduring point is that AHT can cause death and severe lifelong neurologic, visual and developmental disability. [1][10]
Mortality quoted in the slides: 25% Up to 80% of survivors were reported to have lifelong disabilities
- Small head and brain atrophy (61–100%)
- Visual impairment (18–48%)
- Intractable epilepsy (11–32%)
- Those comatose on presentation: 60% died or had profound neurodevelopmental impairment, including cerebral palsy
| Feature | Accidental | Suspicious of Abuse |
|---|---|---|
| Type | Single linear fracture | Multiple, complex, depressed, diastatic (width > 3mm), growing fracture |
| Location | Parietal bone most common | Non-parietal, involving > 1 cranial bone |
| Height of fall | Short falls < 4 feet | Greater force implied |
| Associated intracranial injury | Uncommon | Present |
The table describes associations, not a diagnostic rule: simple linear parietal fractures can be accidental, while complex or non-parietal fractures require careful reconstruction but can also occur in accidental high-energy trauma. Judge compatibility with the full history and associated injuries; do not infer mechanism from fracture morphology or reported fall height alone. [10]
- Broken teeth in older children
- Torn frenulum in infants — particularly concerning in a non-mobile infant and when the history is incompatible, but not diagnostic in isolation
- Pharyngeal injuries
13. Abdominal (Visceral) Injuries [1]
Second most common cause of death from child abuse. Reported case fatalities: 40–50%.
- Direct blows → crushing of organs, hollow viscus perforation
- Indirect shearing forces
- Delay in presentation and diagnosis — the child may not present until shock develops
| Organ | Notes |
|---|---|
| Small intestine (especially jejunum) | Most common hollow viscus injury — compressed against vertebral column |
| Mesentery | Tears from shearing force |
| Liver | Most common solid organ injured (> kidney) |
| Pancreas | Not uncommon |
| Spleen | Rare in NAI (more common in accidental abdominal trauma) |
On the lecture CT examples, solid-organ injury appears as low-attenuation laceration/contusion through the liver or pancreas. Because abdominal injury can be clinically occult, unexplained abdominal pain, vomiting, shock, anaemia or raised transaminases/lipase should lower the threshold for appropriate imaging and surgical input.
| Category | Tests |
|---|---|
| Blood tests | FBC, coagulation screen, LFT, RFT, amylase |
| Urine | Urine microscopy for RBC (to detect renal injury) |
| Radiology | Complete skeletal survey is usually appropriate at ≤24 months when physical abuse is suspected; repeat imaging at 10–14 days when indicated; bone scintigraphy only as a selective adjunct [11] |
| Neuroimaging | CT scan (acute); MRI scan (parenchymal detail) |
Why each test matters:
- FBC: Exclude thrombocytopenia (ITP) as cause of bruising; anaemia from chronic bleeding
- Coagulation screen: Exclude haemophilia or other coagulopathy
- LFT/RFT/Amylase: Detect occult liver, renal, or pancreatic injury from abdominal trauma (especially important as abdominal injuries may be clinically occult)
- Urine RBC: Renal contusion
- Skeletal survey: Detect occult fractures; repeat to find healing fractures not visible initially
15. Caregiver-Fabricated Illness / Medical Child Abuse
“Munchausen syndrome by proxy” is historical terminology. Current child-centred language includes caregiver-fabricated illness or medical child abuse: the essential issue is harm, or risk of harm, from falsified symptoms, induced illness, or unnecessary medical care—not proving a caregiver's motive or psychiatric diagnosis. [14]
- A parent or other caregiver fabricates an illness
- The child is presented persistently for medical assessment, often resulting in multiple procedures
- The perpetrator denies the cause of the child's illness
- Acute symptoms and signs stop when the child and perpetrator are separated
The lecture's demographic and personality profile of a “typical” perpetrator is historical and unsafe as a diagnostic shortcut. Caregivers may present in many ways; friendliness, anxiety, medical knowledge, gender and psychiatric history neither diagnose nor exclude fabricated illness. Focus on objective harm to the child and discrepancies across independently verified records. [14]
- Illness unexplained, prolonged
- Discrepancy between symptoms/signs and history
- Symptoms or reported events occur only when a particular caregiver is present, or are not reproduced during objective observation
- Children alleged to be allergic to a large number of drugs or foods
- High index of clinical suspicion
- Objective verification of medical history
- Review of all medical records (often across multiple hospitals)
- Centralize care, compare reported events with objective observation, and use a multidisciplinary child-protection team
- Covert video surveillance is controversial and not routine; it requires exceptional specialist, institutional, ethical and legal governance. [14]
16. Child Sexual Abuse
Involvement of children in sexual activities that they cannot understand, are not developmentally prepared for, cannot give informed consent for, and that violate societal taboos.
- Perpetrators are usually known to the child and intend to maintain secrecy [1]
- Direct disclosure of inappropriate sexual contact
- Behavioural concerns
- Physical injury to genitals
- Genitourinary symptoms
- STIs
| Level | Features |
|---|---|
| High | Genital injuries inconsistent with accident; severe psychiatric disturbance (mutism, eating disorder, suicide, self-mutilation); repeated sexualized behaviour; marked frozen behaviour; worrying info from adults |
| Medium | Combination of recurrent medical symptoms (unexplained vaginal soreness/bleeding, UTIs, sleep disturbances, anorexia) |
| Low | Isolated sexualized behaviour; single physical symptom without behavioural/emotional problems (e.g. recurrent UTI, vaginal/penile discharge) |
These categories are an older teaching aid, not a rule-out tool. Most symptoms and behaviours are nonspecific, and absence of injury is common. Give greatest weight to a carefully obtained history/disclosure, immediate safety, specialist assessment and corroborating evidence; do not repeatedly question the child.
- Child's safety — safe to go home? Will the child be punished for disclosing?
- Safeguarding and reporting — follow the 2026 SWD pathway and the statutory serious-harm reporting threshold; involve social work and police as the case and current protocol require [8][9]
- Child's mental health — screen for depression, PTSD; trauma symptoms are highly associated with degree of self-blame
- Need for physical examination — by experienced doctor; colposcope; photographic documentation
- Need for forensic evidence collection — arrange urgent specialist referral and follow the jurisdiction's current time window; collect clothing/linens when relevant and maintain chain of custody [15]
- Obtain consent
- Prepare the child — avoid repetitive genital examination
- Use colposcope
- Photographic documentation
NORMAL exams are the NORM — for both girls and boys. [1]
This is counterintuitive but critical: abuse may not have injured the genitals, may not have involved the genitals, or injuries may have healed. A normal examination neither confirms nor excludes abuse. Timely care is essential, but do not deny medical or forensic assessment solely because 72 hours have elapsed: evidence windows vary with age, exposure, specimen and local protocol, and clothing or linens may retain evidence after body swabs no longer do. [15]
- Semen, blood, or hair foreign to the child found within the vagina or anus
- Certain confirmed postnatally acquired STIs can be highly indicative of sexual contact, after relevant perinatal and nonsexual transmission routes have been excluded [13]
| STI | Implication for Sexual Abuse | Action |
|---|---|---|
| Gonorrhoea | Strongly indicative when postnatal acquisition is established | Specialist evaluation and safeguarding report per local law/protocol |
| Syphilis | Strongly indicative when congenital infection is excluded | Specialist evaluation and safeguarding report per local law/protocol |
| HIV | Strongly indicative when perinatal or transfusion acquisition is excluded | Specialist evaluation and safeguarding report per local law/protocol |
| Chlamydia trachomatis | Strongly indicative when perinatal acquisition is excluded | Specialist evaluation and safeguarding report per local law/protocol |
| Trichomonas vaginalis | Strongly indicative after transmission alternatives are assessed | Specialist evaluation and safeguarding report per local law/protocol |
| Condylomata acuminata (anogenital warts) | Suspicious; interpretation depends on age and possible nonsexual transmission | Specialist assessment |
| Herpes simplex (genital) | Suspicious; assess possible nonsexual transmission | Specialist assessment |
| Bacterial vaginosis | Inconclusive | Medical follow-up |
Testing, confirmation and interpretation should follow expert paediatric protocols. CDC guidance treats postnatally acquired gonorrhoea, syphilis, chlamydia, T. vaginalis and non-transfusion/non-perinatal HIV as indicative of sexual abuse, with organism- and age-specific exceptions; anogenital herpes or warts should raise suspicion rather than being treated as proof. [13]
17. Neglect
A severe or repeated pattern of lacking attention to a child's basic needs that endangers or impairs the child's health or development.
| Type | Examples |
|---|---|
| Physical | Failure to provide necessary food/clothing/shelter; failure to prevent injury; lack of supervision; left unattended |
| Medical | Not seeking medical care for sick child |
| Educational | Not enrolling child in school |
| Emotional | Ignoring, withholding affection |
- Chronic neglect can alter biological stress response systems, compromising children's ability to cope with adversity
- More likely to have cognitive problems, academic delays, deficits in executive function, and difficulties with attention regulation
- Negative consequences can be reduced or reversed through appropriate and timely interventions — this is a key exam point that emphasizes the plasticity argument
Acts that damage a child's behavioural, cognitive, affective, or physical functioning:
| Subtype | Description |
|---|---|
| Spurning | Hostile rejecting/degrading — verbal and non-verbal |
| Terrorizing | Threatening to hurt, kill, abandon, or place the child in danger |
| Isolating | Restricting social contact |
| Exploiting/corrupting | Encouraging inappropriate behaviour (criminal, self-destructive) |
| Denying emotional responsiveness (ignoring) | Persistent emotional unavailability |
19. Management of Child Abuse
Multidisciplinary approach. Safety and welfare of the child. Good paediatric care: treat injuries, obtain help for psychological problems, assist in protecting the child from further abuse.
| Stakeholder | Roles |
|---|---|
| Doctor/Nurse/HCP | Emergency Medicine, Paediatrics, Orthopaedics, Psychiatry, Surgery, Neurosurgery, Ophthalmology, O&G, Clinical Psychology, Forensic Pathology |
| Social Worker | SWD Family & Child Protective Services Unit (FCPSU), Integrated Family Services Centre (IFSC), NGO, Medical Social Workers |
| Police | Child Abuse Investigation Unit (CAIU), CID |
| School | Teachers, school guidance teachers, school social workers |
- Case identification and initial assessment
- Crisis intervention and investigations
- Welfare plan and support services
- Social enquiry / investigations
- Medical assessment and treatment
- Joint investigations (school, police)
- Multi-disciplinary case conference (MDCC)
- Follow-up ± review meeting
This remains a useful conceptual sequence, but operational details should follow the 2026 SWD Core Procedures, not the superseded 2015 guide. [8]
- Medical assessment and treatment
- Explain to parents/guardians the management plan
- Strategic planning meeting — preliminary plan
- Activate the current safeguarding/reporting pathway; police involvement and any video-recorded interview are coordinated according to the case and protocol
- Safety issues: other siblings must be assessed
- Home or placement decision
- Multi-disciplinary Case Conference (MDCC)
- Communicate with all stakeholders before MDCC
- Share information
- Determine case nature: abuse, not abuse, or high risk
- Record and notify the case through the current SWD arrangements as directed by the 2026 procedures
- Consider Care or Protection Order
- Welfare plan: placement options (home, relatives, emergency foster homes, foster homes, small group homes, children's home, residential schools)
- Support services: psychological, family & school support, drug services
- Follow-up: review meeting, progress report, family participation
The child sits at the centre of concentric layers of protection:
- Child (centre)
- Family
- School & Neighbours
- Professionals
- Society (outermost)
This model emphasises that safeguarding is a shared responsibility extending from the immediate family to the wider community. [1]
The lecture's service-map diagram adds a second idea: prevention and follow-up are tiered, from universal family resources and Maternal and Child Health Centres, through Integrated Family Service Centres and school/community supports, to specialist paediatric, child psychiatry, medical social work, FCPSU and residential/placement services for higher-risk situations.
- Protecting a child from abuse is the joint responsibility of different professionals
- Priority should be given to ensuring immediate safety of the child
- The safety and welfare of the child should be the paramount concern
- Information sharing on a need-to-know basis
- The child should not be required to repeat the abuse incident(s) except when necessary
1. Be familiar with common manifestations of child abuse 2. Be motivated to report findings 3. Keep a good medical record 4. Be prepared to testify 5. Prevention
| Level | Strategy | Examples |
|---|---|---|
| Primary/Universal | Educate entire community; create social change intolerant of child maltreatment | Mass media, MCHC family & child health services, family life education |
| Secondary/Selected | Focus on those at risk for abuse/neglect | Intervention programs for transition to parenthood; high-risk family assessments |
| Tertiary/Indicated | Treatment for families already affected; prevent recurrence | Family support programs, family group conferencing, parenting skill classes |
The graphs and tables in this deck cover approximately 1995–2018 and should be read as historical surveillance, not current epidemiology. They reported that:
- ~65% of abusers are parents
- 75% of registered cases in children under 2 were neglect in the slide's cited period
- Most abuse occurs at home
Current risk assessment must use the individual child's circumstances and up-to-date SWD data; these historical proportions do not predict whether a particular child has been maltreated.
From the Introduction to Forensic Path lecture [5]:
- Multiple injuries of different types and different ages → think child abuse
- Skeletal injuries, scald/burn injuries
- Account of incident does not match injuries found, or frequently changing account
- ENSURE SAFETY OF CHILD — ERR on the side of CAUTION
Regarding bruises specifically [5]:
- A bruise is caused by blunt force trauma → damage to blood vessels under the skin → bleeding into soft tissues
- Not all blunt force traumas result in a bruise (this was tested in the Nov 2020 MCQ) [4]
- Generally, bruises give no clues as to the nature of weapon or force used
- The colour of a bruise is not a reliable indicator of age
- The size of a bruise is not a reliable indicator of the amount of force
High Yield Summary
- Child maltreatment
- = acts or omissions that endanger a child under 18. Types: physical, sexual, neglect, psychological and mixed. Recognition combines history, developmental plausibility, full examination, careful documentation, medical differentials and multidisciplinary investigation. Bruising is rare in a pre-mobile infant; never date bruises by colour. CMLs and posterior rib fractures are highly concerning patterns, not stand-alone diagnoses. AHT may include subdural haemorrhage, retinal haemorrhage and encephalopathy, but there is no independently diagnostic “triad”; do not date subdural blood by CT density alone. Caregiver-fabricated illness is defined by harm/unnecessary care, not a caregiver profile. In sexual abuse, a normal examination is common; obtain urgent specialist care and follow local forensic windows rather than treating 72 hours as a hard cutoff. Interpret confirmed STIs with organism-specific perinatal/nonsexual exceptions. In Hong Kong, follow the SWD Revised 2026 guide and the statutory serious-harm reporting duty effective 20 January 2026. [8][9][10][12][13][14][15]
Active Recall - Child Abuse
[1] Lecture slides: GC 143. A child with multiple bruises_child abuse.pdf (all pages) [2] Paediatrics block notes: Block C - A child with multiple bruises_ child abuse.pdf [3] Senior notes: Adrian Lui Pediatrics Notes.pdf (pp. 492–493) [4] Past papers: November 2020 Fourth Summative Assessment MCQ paper.pdf (Q21) [5] Lecture slides: Intro to Forensic Path 2023.pdf (pp. 19, 109, 126) [8] Social Welfare Department, HKSAR. Protecting Children from Maltreatment — Procedural Guide for Multi-disciplinary Co-operation (Revised 2026) [9] HKSAR Government. Mandatory Reporting of Child Abuse Ordinance comes into effect (20 January 2026) [10] American Academy of Pediatrics. Abusive Head Trauma in Infants and Children: Technical Report (2025) [11] American College of Radiology. ACR Appropriateness Criteria: Suspected Physical Abuse — Child [12] Royal College of Paediatrics and Child Health. Child Protection Evidence: Bruising systematic review [13] US Centers for Disease Control and Prevention. Sexual Assault or Abuse of Children: STI Treatment Guidelines [14] American Academy of Pediatrics. Caregiver-Fabricated Illness in a Child: A Manifestation of Child Maltreatment [15] US National Protocol / SAFEta. KIDSta Protocol, Section B8: Evidence Collection
GC142 A Child With Loose Stool
A pediatric presentation of diarrhea, defined as the passage of unusually loose or watery stools with increased frequency, resulting from infectious, dietary, malabsorptive, or functional causes requiring assessment of hydration status and etiology.
GC144 A Child With Recurrent Infections Primary Immunodeficiencies
Primary immunodeficiencies are a group of inherited disorders characterized by defects in one or more components of the immune system, leading to increased susceptibility to recurrent, severe, or unusual infections in childhood.