New Screening Tool Identifies Abuse Risk with Single Bruise in Children

Validated Screening Tool Helps Detect Child Abuse Even with a Single Bruise

New research has shed light on an important tool that helps clinicians in emergency departments (ED) identify whether a single bruise on a child could be a sign of abuse. The study, led by Dr. Audrey Raut of Lurie Children’s Hospital in Chicago, highlights how the TEN-4-FACESp bruising clinical decision rule (BCDR) screening tool is effective in making this determination, even when only one bruise is visible.

The tool, which has already been validated to predict abuse in children younger than 4 years, showed an impressive 81.5% sensitivity and 87.6% specificity when used on children with just one bruise. According to the study, a BCDR-positive bruise indicates an increased risk for abuse. These findings emphasize the importance of not overlooking bruises, even if they seem minor or located in an atypical area, as they may signal a much greater concern for potential abuse.

The Significance of Identifying Bruises in Child Abuse

Bruising is the most common sign of physical abuse in children and is often the most overlooked or misdiagnosed injury, especially before a serious injury or death occurs. The TEN-4-FACESp tool was initially validated to assess the risk of abuse based on the location, age, and pattern of bruising in children. Its name comes from the regions of the body that are most concerning when bruised—Torso, Ears, and Neck (TEN) and Frenulum, Angle of jaw, fleshy Cheek, Eyelids, Subconjunctiva (FACES). It also accounts for infants younger than 5 months and the presence of bruise patterns such as slap or grab marks.

Previously, the tool had been validated on children with multiple bruises, but researchers wanted to see how accurately it could predict abuse when only one bruise was visible. The study analyzed children from the original validation study whose only skin finding was a single bruise or injury, such as petechiae or frenulum injuries. Of the 349 children included in the analysis, 27 were identified as cases of abuse.

Findings and Risk Factors for Identifying Abuse

While the majority of the children (92.3%) had accidental injuries, the study found distinct characteristics in the children who were victims of abuse. Children with abusive injuries were generally younger, less likely to have a direct injury complaint, and more likely to have a bruise in a region flagged by the BCDR tool. Additionally, these children often had psychosocial risk factors, such as prior involvement with law enforcement or Child Protective Services. They also had a lower Glasgow Coma Score, suggesting a more serious injury.

The researchers noted that while a positive BCDR result can be a helpful tool for recognizing abuse, clinicians must be cautious with negative results, as false negatives were more common in this study compared to the original validation study.

Importance of Clinical Decision Tools in Identifying Abuse

The accompanying commentary by Dr. Tagrid M. Ruiz-Maldonado and Dr. Suzanne B. Haney emphasized the importance of using clinical decision support tools like the TEN-4-FACESp to guide decision-making in potential abuse cases. These tools help providers make objective decisions and avoid being influenced by emotional responses when there is uncertainty about whether an injury is accidental or abusive. It is crucial, however, to remember that the TEN-4-FACESp tool is not a diagnostic tool. Pediatricians and specialists are key in interpreting the findings and making clinical decisions.

The study's findings hold particular relevance for general pediatricians and pediatric subspecialists who are on the front lines of child abuse detection. These tools provide valuable support, but experts in child abuse pediatrics must still provide the final clinical input, especially in cases where the diagnosis is uncertain.

Study Reference: https://publications.aap.org/pediat...ics-Associated-With?autologincheck=redirected

Conclusion and Future Directions

This study underscores the importance of utilizing validated screening tools like TEN-4-FACESp to help identify signs of abuse in children, even when only a single bruise is visible. As bruising is often the first indicator of physical abuse, early identification can lead to timely intervention and prevent further harm to the child. While no tool is perfect, the ability to predict the risk of abuse with a high level of sensitivity and specificity can assist in preventing tragic outcomes.