Accident or child abuse?

Figure 1. Hyphema at 24 hours at clinic presentation.

Accidents are bound to happen in all populations, especially with active children. Active listening, case history, and clinical findings differentiate between accident and abuse. Analyzing subjective and objective findings will allow the OD to make the decision if an accident or abuse occurred.

Case reports of ocular trauma from accidents and abuse are presented with subjective and objective findings and clues that help the practitioner discern one from another.

Related: Identifying and responding to child and elder abuse 

By the numbers
Children youth, and teens experience high levels of victimization. Crimes against young people can range from abuse and neglect to assaultive violence and homicide. There were 686,000 child maltreatment victims or 9.2 per 1000 children in 2012.1

In 2012, 44 percent of all child maltreatment were white, 21 percent were African American, and 21.8 percent were Hispanic. Of those children, 36.6 percent of the time the mother was the perpetrator, 18.7 percent of the time the father was the perpetrator, and 12 percent of the time someone other than the parent was the perpetrator.¹

Breaking down abuse cases by category:¹

78.3 percent neglect
18.3 percent physical abuse
10.6 percent other abuse
9.3 percent sexual abuse
8.5 percent psychological maltreatment
2.3 percent medical neglect

Neglect (29.7 percent) and physical abuse (24.6 percent) have the highest percentage of children aged two years and younger. Teens age 12 to 14 have the highest risk of sexual abuse (26.3 percent).¹

Girls and boys are victims of abuse at a rate of 9.5 per 1,000 children and 8.7 per 1,000 children, respectively.¹

An estimated 1,593 children died as a result of maltreatment in 2012. Forty-four percent of these children were under a year old. Eighty percent of child fatalities were caused by the child’s parents. Twenty-seven percent of fatalities were caused by the mother alone, 8.6 percent of all homicide victims were children and youth under the age of 18-of that number 52.8 percent were aged 17 to 19 years.¹Related: Know the OD's role in substance abuse 

The big picture
When patients and parents of pediatric patients complete intake forms and speak with staff, pieces of patients’ stories may not add up.

In addition, when ODs’ subjective and objective findings may not be congruent. The ocular tissues can tell a story of motion and injury that may not be supported by the story that was told. Some conditions, like concussion, may not have clear objective findings and will need further diagnosis.

As mid-level health care providers, ODs are obligated to report suspected abuse or neglect. Abuse could be physical, verbal, or neglect of needs. ODs will see bruises to eye and adnexa during patient care. History and observations must support clinical decisions. A robust-looking child wearing a dirty baseball uniform with a black eye who says he was hit with a baseball presents differently than a skinny kid who says he fell into a doorknob.

Related: Maintain open communication with primary-care physicians 

Other signs of physical abuse include bruises of different ages. Naturally occurring bruises are on the knees, elbows, and bony extremities. Questionable bruises may show up as small finger-size marks from squeezing too tightly or larger marks from blows from a hand, fist, or foot from being kicked.

Bruises to orbital rim, eyelids, and adnexa, and subconjunctival hemorrhage may show after a choking episode. Note that these conditions could show up in a healthy child after a bout of coughing or vomiting.

Retinal hemorrhages are a key finding in shaken baby syndrome.² There are non-abusive findings for a retinal hemorrhage in a child. Leukemia, sickle-cell disease, and diabetic retinopathy would be differential diagnoses.³

Observe the cleanliness of child, as well as her face, clothing, hair, hands, and fingernails. Look at weight and overall appearance-the child should look well-nourished and healthy.

Beware of stories that do not add up. A child may say, “I fell and hit my eye.” When asked or even unprompted, the child may later say something different.

Abused children may not answer truthfully when someone else, especially the abuser, is in the room. If an OD has suspicions about the origin of physical findings, attempt to speak with the child out of earshot of others.

Ocular signs of child sexual abuse include:

• Pubic lice on the eyelashes and adnexa
• Presentation with sexually transmitted diseases like chlamydia or gonorrhea
• Streff's syndrome

Red flags for abuse that may present in the exam room include:⁴

• Excessive crying
• Doing poorly in school
• Fear of certain people, things, or activities
• Anger and/or aggression

Consider that abuse for girls often takes place prior to puberty because the offender does not want to risk pregnancy. The patient’s case history may lead the OD to report for investigation.

Related: 3 mental health conditions to watch for in patients 

What ODs can do
If an OD suspects that a child is being harmed, report concerns to the appropriate authorities-local child protective services (CPS) or the police department.

The role of the physician includes preventing child abuse and detecting and treating victims of child physical abuse when it occurs. The physician’s ability to recognize suspicious injuries, conduct a thorough physical examination, and evaluate the validity of the caregivers’ explanations for injuries is important in detecting child abuse.

The American Academy of Pediatrics (AAP) recommends that physicians ensure that a patient who is a victim of child physical abuse receives proper medical assessment, stabilization, and referrals to investigative agencies and necessary follow-up services, which include patient and family referrals to appropriate psychological professionals.¹Related: Reviewing pediatric primary care optometry 

Brief cases below outline potential abuse cases and how they were handled.

Case 1
A 17-year-old white male presents to clinic with his mother holding a wet washcloth to his eye. Visual acuity was reduced to 20/70 with 30 percent corneal abrasion and 25 percent hyphema. Patient was “popped” in the eye by another student with a towel in the locker room.

Treatment was bed rest, homatropine 5%  bid, Pred Forte (prednisolone acetate, Allergan) Q4h while awake. Complete resolution of the abrasion and hyphema occurred within 14 days.

This case is consistent with horseplay and bullying. A single incident may trigger suspicion, but the story is plausible and there were no other incidents of injury for this youth.

Case 2
A 10-year-old boy presents to clinic with painful left eye. His visual acuity OD 20/20, OS 20/80. His left eye showed a 5 mm corneal abration and anterior chamber 2 percent hyphema. His history indicated being shot with a Nerf gun at close range by a playmate.

The patient was managed with homatropine 5% and Maxitrol (neomycin, polymyxin B, dexamethasone; Novartis). Bed rest was advised because hyphema is at risk for re-bleed within the first week.

Considering accident versus abuse or neglect, it is unclear if lack of eye protection would constitute neglect.

Case 3
An 11-year-old girl from Nigeria presents with her father for routine exam. Father calls her stupid and berates her. Doctor wants to dilate her, and child resists. Father takes dilating drops, slaps the child on the face, and puts eyedrops in the child’s eyes.

Is that enough to call the police and take the child into protective custody?

Developing policies and procedures to manage challenging situations like this are often implemented on a case-by-case setting. These policies should consider child safety and legal consequences for moving forward. There are cultural differences, but ultimately children are protected by local laws in the United States.

Case 4
A 5-year-old male presents with left exotropia. His visual acuity is OD 20/20, OS NLP. The patient has a history of his biological father punching him in the left eye. Plus, the child was hospitalized from the beating and accompanying head injury.

The patient experienced traumatic cataract and complete retinal detachment of the left eye resulting from this beating.

The father was convicted of child abuse, and the child was removed to protective services.

Case 5
A 6-year-old male reports for a pre-kindergarten exam. He had trouble with letter reversals and attention in the classroom. He has a history of shaken-baby syndrome at age 3 months with hospitalization.

The patient’s mother was convicted of child abuse and subsequently gave birth to his sister while in prison. Both children are in the custody of their maternal grandmother who is raising them as a single parent.

The patient’s visual acuity is 20/20 OD, OS, and OU. His refractive error OU is low plus. Binocular findings show reduced near point of convergence, poor fixation on pursuits, and undershot all meridians with head and body movement on saccades.

Glasses for hyperopia and accommodative concerns were prescribed. Vision therapy for tracking and convergence challenges was initiated.

Related: Controversies in pediatric refractive development 

Conclusion
ODs should follow their guts. If you an OD thinks something is not right with a child or family, be cautious.

Develop relationships with localschool personnel; there may be other reasons to get a principal or school counselor to involve authorities. An OD’s observations and input may be another piece of the puzzle.

Also develop relationships with police and child abuse investigators. Be sure to respect the doctor-patient relationship while addressing concerns.

Child abuse and neglect are prevalent. Ocular signs and symptoms may be managed and reported appropriately. As primary-care providers, ODs may be more accessible and available to help with keeping children safe.

Read more pediatric articles here 

About the author Dr. Howell completed her Doctor of Optometry at Southern College of Optometry, and she returned to complete a residency in pediatrics and vision therapy after practicing for 20 years. She co-authored a textbook chapter on ADHD and ocular side effects of behavioral medicines in Visual Diagnosis and Care of the Patient with Special Needs. In her free, time she enjoys music and gardening for food and flowers. 
drangelahowell@yahoo.com

 

References:

1. Child, Youth, and Teen Victimization. The National Center for Victims of Crime. Available at: https://victimsofcrime.org/docs/default-source/ncvrw2015/2015ncvrw_stats_children.pdf?sfvrsn=2. Accessed 8/7/19.
2. Togioka BM, Arnold MA, Bathurst MA, Ziegfeld SM, Nabaweesi R, Colombani PM, Chang DC, Abdullah F. Retinal hemorrhages and shaken baby syndrome: an evidence-based review. J Emerg Med. 2009 Jul;37(1):98-106.
3. Maguire SA, Lumb RZ, Kemp AM, Moynihan S, Bunting HJ, Watts PO, Adams GG. A systematic review of the differential diagnosis of retinal hemorrhages in children with clinical Features associated with child abuse. Child Abuse Rev. 2013 Jan/Feb;22(1):29-43.
4. Stanford Medicine. Signs & Symptoms of Abuse/Neglect. Available at: http://childabuse.stanford.edu/screening/signs.html. Accessed 8/6/19.