DERMATOLOGIC MANIFESTATIONS

     Most obvious within the examples of child abuse are the results of physical trauma to the child. Resulting in soft tissue injuries, these signs are the most dramatic and are therefore easily recognized by the trained medical professional. All falling into this category, hematomas, abrasions, contusions, and ecchymoses are the most commonly found symptoms. It must be noted however: they are also common in non-abused children. It is the physician's expertise which must determine whether or not wounds of this physiology were inflicted intentionally. Lacerations (cuts), for instance, are known to be more often accidental than intentionally-inflicted. The location of an injury is important in making a decision as to its cause. "Injuries to bony prominences of the trunk and of the extremities are just as likely to have been accidental in nature as they are to be abuse-related. This also holds true of the head area and of the preorbital area. Injuries to the cheeks, genitals, buttocks, thighs, neck, and back, however, are more likely to have been caused by abuse. The shins, knees, hands, and elbows are commonly accidentally injured by children all of the time, and so should not arouse immediate suspicion of child abuse or neglect."

     The ages of injuries are important. If injuries of varying stages of healing are present (and therefore to have been of varying stages of infliction), child abuse should be suspected. One cardinal sign of abuse is a discrepancy between the physical findings and the history presented to the physician by the parent(s) or guardian(s).

     Bruises are frequently morphologically similar to the implement used to create them. Hand print of belt buckle marks are often easily defined as such. The most common marking in these types of traumas is the "loop" mark. These are inflicted with the use of a flexible object such as a clothesline or electrical cord being folded over and used as a whip to beat the child. Multiple marks on a child, of this nature, are pathogonomonic of intentional, repetitive abuse. Circumferential marks around the neck, wrists, or ankles are most probably caused by restraint of the child. Scarring of this nature indicates past restraint.       [55.]

     Baldness can be indicative of traumatic alopecia, which is caused by the abuser repeatedly pulling the victim's hair. Especially in younger children and teenagers, baldness should be considered highly suspicious, barring any other obvious medical reasons for its occurrence. Malnutrition can be a cause of hair loss, and this is often found in children with other failure-to-thrive symptoms. Not all children who are malnourished exhibit this, however. Another cause of baldness in children is trichotillomania: the pulling out of one's own hair. This is a behavioral problem, resultant of an underlying psychosis, such as those often found within children and adults who were victims of child abuse of one nature or another.
 

SIDS AND OTHER "MEDICAL MYSTERIES"

     Sudden Infant Death Syndrome (SIDS) remains a problem for medicine. There have been cases however, where babies have been intentionally suffocated. Sometimes the only physical manifestations are cyanosis and apnea. In these cases, it is likely that the death was accidental and truly attributable to SIDS. If other signs, such as bleeding gums or pinch marks on the alae nasi are found, then foul play should be suspected.
 

     It must be kept in mind - that which appears as a medical "mystery" may very well be the result of bizarre human behavior. In one case, a child was being evaluated for immune deficiency. She was having recurrent bacterial infections of her skin and soft tissues. It was discovered that the child was repeatedly infected in this manner because her mother (if one could call her that) was repeatedly injecting fecal matter into her skin and was withholding antibiotic treatment prescribed by the doctors. Child maltreatment is a more commonly-found problem than are rarer diseases such as immune deficiency.

     Neglect can be determined in many ways by the physician: especially medical neglect. Abscesses, fissures, lymph node enlargement, or necrotic tissue usually indicates that the illness has been present within the child for an extended period of time - long enough for the parent to have sought medical help. When common dermatologic problems, such as impetigo, eczema, scabies, pediculosis, or seborrhea have not responded to the doctor's prescribed course of action, noncompliance with medical recommendations should be suspected. The parent should be reported as neglectful, so long as the physician is positive of his diagnosis.

     Physical neglect of a child can present itself in many different ways. Some of the more common signs are feces and dirt under the child's nails, on his skin, or on his clothing. If a child has dog or rat bites, it would be prudent to have someone such as a social worker investigate to see if the child is being left alone for long periods. Repeated skin infections can result from inadequate bathing. Frostbite can indicate that the child has been left outside in cold weather without adequate protective clothing.

     It must be stressed that despite the severity of the physical abuses listed herein, emotional abuse of children is often far more devastating on the life of the child.  [56.]

     Emotional and psychological sequelae  may manifest as self-inflicting sucking, scratching, head banging, rubbing, or biting. These all have recognizable cutaneous patterns. Although self-mutilation is not a necessary result of child maltreatment, many behavioral and personality problems seen in adults and children are attributable to recognized or unrecognized child abuse. Although the physician should not jump to the immediate conclusion that the underlying cause is child abuse, psychological evaluation and assessment of family dynamics is warranted.
 

Lasting Effects ................................................................................................................................
 

     "Many victims of abuse use anger for their own protection - as a shield to prevent anyone from getting close to them," says Della Hughes, Executive Director of the National Network of Runaway and Youth Services. "They are hurt and angry about what happened in their lives. They expect to be abused by all people in authority, be it teacher, police officer, or juvenile court worker...  Unfortunately, most of us fail to recognize the history that lies behind the anger and that the anger is serving a healthy purpose. Instead, we tend to further victimize these youths by further punishing them for being rude and abrasive. "    [57.]

     "Underneath the obnoxious behavior is an extremely hurt child who has put up emotional barriers so she will not get hurt anymore by adults. Sexually abused children feel they've been lied to and no one has taken the time to understand what is going on inside of them. Usually that child starts to become comfortable with negative attention instead of positive attention. It's a form of being noticed and a way of getting their anger out. You know, 'Go ahead and hit me. You think I'm going to be a slut or a whore, fine; that's exactly what I'm going to be, and I'm going to be great at it.' Underneath they desperately need somebody to get past all the baloney. They desperately want someone to get down to how they feel and what's happening to them. At the same time they'll fight that very effort because they are scared.

     "Retardation remains the neuro-developmental problem of most concern in surviving abused children.

     "Trauma to the head can result in hemorrhage, edema, atrophy, death of neurons, or hydrocephalus. Even shaking of infants has been shown to cause bleeding within the skull so that biological damage to the brain can occur without a history or without signs on physical examination of assault to the head of a young child. The entire panorama of neurologic sequelae may follow these pathologic processes, with the most commonly noted being mental retard-ation, cerebral palsy, neuromotor dysfunction, seizure disorder, learning disabilities, and sensory impairment."    [58.]

     There is an increased frequency of illness in abused children. This fact alone raises several questions, among them the consideration that  parental neglect may play a role in the unhealthy child having less opportunity for learning. Abused children are also at higher risk of malnutrition, anemia (usually iron deficiency), poor dental health, and hearing deficits. Oftentimes they demonstrate poor hygienic habits and are also often inadequately immunized, if at all.

     Some abusive families also emotionally neglect their children, and some do not. Neglectful parents are basically those who are not interested in the child's welfare. They fail to supply adequate nurturance and understanding. In layman's terms, there is insufficient love for the child. Love is an essential ingredient, needed for normal psychological growth and development of any child. "A substantial minority of abused children come from such homes. The emotional deprivation the child suffers is usually more potent than the physical assaults in leading to psychic trauma and distortions of personality.

     "Competence and mastery are difficult to obtain in the abusive home. When the child attempts to learn new facts, skills, or abilities, there must be partial successes, bungled first-attempts, and incomplete approximations to successful mastery. In the abusive home, these burgeoning attempts at success will likely be met with derision, punishment, anger, or other extinguishing responses. How can the infant and child learn when his attempts at mastery and competence are unacceptable because they are not complete, perfect, or successful? When this dynamic is coupled with the child's own poor sense of himself, the developmental line of mastery and competence is barricaded."   [59.]

     Grieving and mourning behaviors of a child can only serve to interfere with learning and socialization. Rebellious protest, and the later apathetic and/or depressive demeanor essentially rob him of being alertly available to learn, to play, or to enjoy interpersonal relationships. In addition, the child must sometimes deal with the stress of adapting to a new and strange environment, such as a foster home.
 

Revealing Abuse ............................................................................................................................

     Not all victims of child abuse are eloquent. Many times, abuse victims are nearly inarticulate, altogether. Many  have yet to find anyone who will listen; who they can vent their internalized frustrations about what happened to them onto. Their silence all too often leads to a muteness. Then the muteness leads to a numbness of their souls.

      What we do know is that child sexual abuse has devastating consequences for children. Many carry enormous feelings of guilt and responsibility (even though their victimization is not in any way their fault) throughout their childhood and adult lives. Typical characteristics of many victims are low self-esteem, clinical depression and an inability to have positive and satisfying personal and sexual relationships.

IT'S EVEN HARDER FOR BOYS

     Despite the difficulty which girls face in trying to talk about their abuse, as mentioned earlier, in somewhat less detail, it is even harder for abused boys. He must admit weakness and victimization in order to report what occured. Dr. Rader * says: "If a boy is molested by a male, he will fear that this has made him a homosexual. He believes he must be homosexual and then he might spend time being homosexual feeling it's bad, dirty, and wrong. The greater percentage of homosexuals know they are homosexuals at an early age. Homosexuality is a normal state for them. But there are some who go this direction because of incest and feel that's what they should be; that that is what they deserve. By acting out homosexuality, these people treat sex the way addicts do: there's no feeling in conjunction with the sex. And the sex is furtive - it's here, there, everywhere, no real intimacy. The act makes them feel degraded, but it takes the pain away and makes them feel okay for the moment."    [60.]

POST TRAUMATIC STRESS SYNDROME

     Abuse survivors are commonly treated for post-traumatic stress disorder, also known as PTSD. They live with constant and sometimes crippling anxiety. The symptoms of PTSD were seen in some returning Vietnam War veterans. It is also frequently demonstrated by victims of torture. Affected individuals suffer nightmares, flashbacks, amnesia, unexplained fear and anger, and severe anxiety. Cheryl Crane [see "Survivors" section of report] often recalls "leaving her body" during her abuse at the hands of her mother's third husband. It is a way that the mind of some abuse victims reacts. They disassociate themselves from the horror of the act. They temporarily are "just aren't   there." Often, victims continue to disassociate for decades after the abuse ends. The longer the duration of abuse, and/or the more severe the trauma, the more likely the victim will develop PTSD.   [61.]
 
 

          *  Dr. Rader is cited often in Suzanne Somers' book "Wednesday's Children"
 
 

INABILITY TO TRUST PEOPLE/ SOCIETY AT LARGE/ AUTHORITATIVE INSTITUTIONS

     "A sexually abused child or adult has great difficulty with trust. A patient of Dr. Rader tells that age five her father raped her. "Yet she was convinced (at age 28) that it was she who had seduced her father. She was convinced this was the issue. She was afraid to intimate with someone because that person would come close to her awful truth. In addition, there is that basic Pavlovian conditioning going on. After so much betrayal by the abuser through sexual intimacy, it's hard for the victim to trust anyone with whom she is sexually intimate. The victim thinks, 'My father did this, so how do I know you're not going to stab me in the back in the middle of lovemaking?' Of course, this is never discussed. This is not even thought about; and, of course, they'll be faking orgasms because an orgasm might trigger the early orgasms or the early feelings of good. So how can they ever allow themselves to be fully vulnerable again?"     [62.]
 
 

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