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Abstract
Objective To determine the frequency of recent skin injuries in children with neuromotor disabilities and its association with disability.
Design Cross-sectional study of 168 children with neuromotor disabilities aged 2–16 years.
Setting Two outpatient child rehabilitation centres.
Main outcome measures Children were classified as unrestricted walkers, restricted walkers or wheelchair dependent. Each participant's body surface was systematically examined for recent skin injuries with the exception of the anal-genital area.
Results The mean age of our sample was 7.8 (SD 3.7) years with a 3:2 male/female ratio. Overall, 64% had cerebral palsy, 17% a neuromuscular disease and 19% other motor disabilities. Participants had on average 5.3 (SD 4.5) recent skin injuries (max 19), of which 2.5 were bruises (SD 3.3, max 16), 2.4 were abrasions, scratches or cuts (SD 3.0, max 16) and 0.4 were pressure lesions (SD 0.8, max 4). There was a significant decrease in the frequency of recent skin injuries and of bruises with increasing severity of motor disability. Most of this variation was accounted for by injuries to the lower limbs. There were no significant effects of gender, learning disabilities or other comorbidities.
Conclusions Children with neuromotor disabilities present a progressive reduction in the number of skin injuries with decreasing mobility. Therefore, recent skin injuries in this population which are unusual by their number, appearance or distribution, should raise at least the same level of suspicion for physical abuse as in children without disabilities.
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Introduction
Skin injuries are the most frequent and easily recognisable signs of physical abuse in children. According to studies, between 28% and 92% of victims of child abuse present with skin injuries.1 However, it is difficult to differentiate the usual lesions related to daily activities and play, from those that are non-accidental, especially since the great majority of children aged 9 months and more who move independently present at least one recent skin injury at any time.2 Differentiating usual daily life injuries from those that are suggestive of abuse is therefore essential.
The disabled child is particularly at risk of physical (but also emotional and sexual) abuse. In their population-based study of 50 000 children, Sullivan and Knutson3 determined that 31% of children with disabilities had a history of ill treatment against 9% in the standard population. The incidence of abuse was particularly increased in the presence of behavioural difficulties and language or mental impairment, but was also significantly elevated in cases of isolated physical disabilities. Dawkins4 studied the prevalence of bullying and physical attacks in a mainstream school setting in 57 children with a visible physical impairment and 46 unaffected children and showed that disabled children were bullied twice as frequently as their able-bodied peers (30% vs 14%).
What is already known on this topic
Child disability is a risk factor for physical and other forms of abuse.
A significant proportion of abused children present skin injuries.
What this study adds
The frequency of recent skin injuries decreases with increasing severity of motor disability.
Unusual skin injuries should raise at least the same level of suspicion for physical abuse in children with disabilities as in children without disabilities.
A research letter5 describing a small pilot study seemed to indicate that bruising, particularly on unusual sites which are usually suggestive of abuse (buttocks, face), is frequent in disabled children. The authors therefore suggested that children with disabilities or special needs may have very different bruising patterns compared to their able-bodied peer group.
Assuming that disabled children are at risk of physical abuse, first-line practitioners and caregivers require appropriate knowledge of the normal frequency and distribution of recent skin injuries, in order to detect and assess potential abuse situations. The aim of our study was to establish the prevalence and typology of skin injuries in children with motor disabilities in the absence of suspicion or evidence of abuse, as well as to determine the risk factors for these lesions, especially in terms of the severity of the disability.
Methods
Design and participants
This observational study was conducted over a period of 1 year (between 1 July 2007 and 30 June 2008) in two tertiary outpatient rehabilitation centres for children with motor disabilities (Lausanne and Lyon-Sud University Hospitals). Candidates were consecutively recruited on attending their routine follow-up clinical appointments.
We included children aged 2–17 years old who presented a motor disability as one of the main features of their disorder (eg, cerebral palsy, neuromuscular diseases, spinal dysraphism, acquired cerebral or spinal motor disability, metabolic and other progressive encephalopathies). Children were included once if they attended more than one visit over the study period. Participants with confounding skin lesions (eg, widespread atopic dermatitis) or who had been suspected or alleged victims of abuse at any stage of their follow-up were excluded. The suspicion of physical abuse was based on characteristic skin lesions (imprints), lesions physically incompatible with the child's motor abilities (eg, bite marks on the hand of a child with muscular dystrophy unable to lift their hand to their mouth), or the observation or secondhand knowledge of an abusive parent–child interaction.
Informed written consent was obtained from the parent or legal guardian of all participants, and from the child when possible. The study was approved by the local ethics committee.
Data collection
Standard demographic (age, sex, ethnicity), anthropometric (weight, height, tricipital skin fold) and clinical data were collected, including information on the primary diagnosis, comorbidities (eg, epilepsy, malnutrition), medication as well as associated cognitive or sensory disabilities. Regarding motor function, children were classified into three groups: unrestricted walkers (children can walk unhindered at home, school, outdoors and in the community and are able to walk up and down stairs without physical assistance), restricted walkers (children can walk in different settings but experience difficulty walking long distances and/or on uneven terrain and inclines, may walk up and down stairs but with physical assistance, may require assistive devices and/or orthoses for ambulation) and wheelchair dependent (reliant on a wheelchair for home, school and community mobility). The degree of learning disability (mild, moderate, severe) was most often estimated clinically, unless an intellectual quotient was available.
Each participant's body surface, including the breast and buttocks, was systematically examined by one of the investigators (CJN, CHG, CV) with the exception of the anal-genital area. The characteristics and topography of all recent skin injuries were recorded on a standardised body chart. For size, maximum length and where applicable width were measured by using a standard tape measure. Lesions were individually classified into four main types: bruises, lesions with loss of skin integrity (abrasions, scratches, cuts), pressure lesions (persistent pressure marks with redness, blisters, ulcers) and others (eg, bite marks, burns). All the body charts were collected by a single examiner (CJN) who extracted the data regarding number, distribution and type of lesions. The parents and child (when possible) were questioned about the cause of each injury. This examination took place within the complete examination performed during the routine visit.
Statistical analysis
Statistical analyses were performed using SPSS V.15. General features of the study population and lesion characteristics (distribution, causation) were analysed by frequencies and cross-tabulations. We compared the mean frequency of skin lesions (total number of lesions and by injury type) between groups that were based on physical characteristics (diagnosis, mobility, epilepsy, visual impairment), personal (sex, age, learning ability) and environmental factors (schooling system – mainstream vs special needs) by performing one-way analyses of variance (after homogeneity of variances was tested for all main outcomes using the Levene's test, p>0.05). Proportions of lesions were compared by contingency tables and χ2 tests. p Values <0.05 were considered significant.
Results
General characteristics
A total of 168 children were included (137 in Lausanne, 31 in Lyon). We excluded four children with confounding skin lesions (three generalised atopic dermatitis, one diffuse angiomatosis), six suspected and one alleged victims of abuse. Four teenagers and one family refused to take part.
The mean age of our sample was 7.8 (SD 3.7) years with a 3:2 male/female ratio. Proportions of children in each age group were as follows: 20%, 2–4 years; 33%, 5–7 years; 21%, 8–10 years; 17%, 11–13 years; 9%, 14–17 years. Overall, 64% of children had cerebral palsy (26% unilateral spastic, 26% bilateral spastic, 5% ataxic, 3% dystonic/dyskinetic, 4% mixed), 17% had a neuromuscular disease, 5% had a spinal dysraphism and 14% other motor disabilities (acquired cerebral and spinal disorders, neurometabolic and neurodegenerative diseases). Of participants, 33% walked with no restrictions, 39% were restricted walkers and 28% depended on a wheelchair for their mobility. Data regarding diagnoses and associated mobility categories are summarised in table 1. Participants presented the following comorbidities: 12% had mild, 9% moderate and 19% severe learning disabilities; 15% had epilepsy (6.5% with one seizure or more during the previous month); 5% presented a significant visual impairment. As regards education, 13% of children were at home full time, 56% attended mainstream preschools or schools, 29% attended special needs schools as externs and 2% were special needs school residents.
Baseline medical data with number in each diagnostic category (CP) and mobility levels
Skin injuries
A total of 882 injuries were observed, 357 for unrestricted walkers, 366 for restricted walkers and 159 for wheelchair-dependent children. There were 417 bruises, 397 lesions with loss of skin integrity, 64 pressure injuries and four others.
Eighteen children (11%) had no skin injuries: 2/55 (3%) independent walkers, 4/66 (6%) dependent walkers and 12/47 (26%) wheelchair-dependent children (χ2 13.4, p=0.001).
Participants had on average 5.3 recent skin injuries (SD 4.4, max 19), of which 2.5 were bruises (SD 3.2, max 16), 2.4 were lesions with loss of skin integrity (SD 3.0, max 16) and 0.4 were pressure lesions (SD 0.8, max 4). Injuries predominated in the lower limbs, with an average of 3.4 lesions (SD 3.0, max 16), followed by the upper limbs with 1.2 lesions (SD 1.9, max 13), trunk (including buttocks) with 0.5 lesions (SD 1.2, max 11) and head (including neck) with 0.2 lesions (SD 0.5, max 3).
There was a significant decrease in the frequency of recent skin injuries and of bruises with increasing levels of motor disability (table 2, figure 1). Most of this variation was accounted for by injuries to the lower limbs (table 3), specifically to the leg and knee areas. There were no statistically significant effects of age, gender, schooling system, learning disabilities or co-morbidities on the frequency of skin injuries.
Mean number±SD (range) of skin injuries per subject, according to mobility category
Box and whisker plot of mean value of skin injuries (with 95% CI) related to mobility.
Mean number±SD (range) of total skin injuries per subject, according to mobility category and localisation
Injuries to body areas directly suggestive of abuse were infrequent. Proportionally to all observed injuries, 2.0% (n=18) were situated on the buttocks (all in children aged between 5 and 14 years old) and 0.2% (n=2) on the chin, ears or neck. There were no significant differences between mobility categories. Buttock injuries represented 2.0% (n=7) of all injuries for unrestricted walkers, 2.5% (n=9) for restricted walkers, and 1.3% (n=2) for wheelchair-dependent children (χ2 0.8, p=NS). We observed one chin injury in a 2-year-old independent walker from a fall, and one neck injury in a wheelchair-dependent 11-year-old child from a cat scratch.
There was significant variation in the causation of injuries between the different mobility categories, favouring falls for the walkers versus equipment use, handling and self-inflicted injuries (scratches, bites, other self-mutilations) for the wheelchair-dependent participants (table 4).
Proportions and counts (% (N)) of skin injuries reported by participants and/or their parents according to causation and mobility category
Discussion
Our study is the first, to our knowledge, to comprehensively assess recent skin injuries in children and adolescents with motor disabilities. A previous case series5 described 14 children aged 15 months to 4 years, in a special needs preschool setting, with a variety of disabilities (not specified) and indicated a high prevalence of bruising, especially in locations that are usually suggestive of physical abuse (36% children with bruising to the buttocks, 29% to the neck and face). These unusually frequent patterns of bruising were not replicated in our study, with only infrequent to rare occurrences of injuries in these areas (2% to the buttocks and 0.2% to the ears, chin or neck); furthermore, in the 34 children aged 2–4 years only one child had a lesion to the chin.
Overall, 97% of the independent walkers in our study presented one injury or more. Previous research has demonstrated the high likelihood of identifying at least one skin injury at any single time in ordinary children, with percentages that vary from 37% to 100%.2 6,–,8 Some of our independent walkers presented a high number of injuries (maximum 19). There is also a wide variability in the number of skin injuries in children with no disabilities, with more than 20 skin injuries (up to 39) observed in rare cases,2 after child abuse or an underlying medical problem had been ruled out by an extensive medical and social evaluation.
The single predictor that influenced the occurrence of skin injuries in this study was the participants' degree of mobility. With decreasing mobility there was a clear and significant decrease in the frequency of all skin injuries, especially bruises. In terms of topography, it is mainly the difference in frequency of injuries to the lower legs and knees, that are typically associated with falls, which accounted for this decrease.
Restricted walkers, who may be believed to be more prone to falls due to lack of balance and motor control compared to ordinary children,9 may in fact experience a reduction in their total motor activity and are often slower and more cautious than their able-bodied peers, and are therefore probably less exposed to the events of daily life that classically provoke accidental skin injuries, such as falls or collisions.
Patterns of causation differ strongly for children who are wheelchair dependent, since self-inflicted injuries, skin lesions due to the use of equipment (most frequently on the foot or ankle, due to the use of lower limb splints), and those due to handling by an adult, clearly outweigh those observed in walking participants. However, the frequency of these injuries is low and overall the total number of lesions remains clearly below that observed in walkers. Regarding self-inflicted lesions, the excess in this population is certainly due to the increase in self-injurious behaviour in severely disabled children who more frequently present co-morbid cognitive and behavioural disorders.
Interestingly, the proportion of lesions of unknown origin was consistently high (34–40%) in all mobility categories. This most likely reflects the fact that an important number of benign and minor skin injuries encountered in daily life go unobserved, and that a parent and/or child not providing a clear explanation for certain injuries is alone not sufficient to raise suspicion for a non-accidental aetiology.10 11
One of the limitations of this study was the lack of a control group of non-disabled children that would have allowed us to clearly infer differences and similarities with a normal age-matched population. A degree of observer bias in the recording of skin injuries may have been present, since they were recorded separately by three investigators; however, we attempted to reduce this by an initial thorough discussion of the observation protocol and by having a single investigator extract the data from all the body charts. Our sample size allowed us to clearly demonstrate the effect of mobility on the frequency of skin injuries, but it is possible that with a larger sample other factors such as age, medical diagnosis or comorbidities (eg, learning disabilities) may also have shown an effect. Finally, it is impossible to assert that none of the observed injuries were of an abusive nature despite the examiners' awareness of this possibility; however, we believe that these situations would be rare, and would certainly not interfere with our conclusions.
Child disability is a clearly recognised factor in abuse, however both to avoid an unnecessary climate of suspicion and to provide the baseline knowledge that can lead to the detection of potential physical abuse, it is necessary to have a clear image of what skin injuries can be considered as usual in disabled children. We believe that guidelines of detection that apply to the general population that take into account common anatomic sites of abusive versus accidental bruising as well as abuse ‘red flags’ such as repeated emergency room visits or delays in seeking medical care, are also valid for disabled children,10 11 and that recent skin injuries that are unusual by their number, appearance or distribution should raise at least the same level of suspicion as in children without disabilities.
Footnotes
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Funding Anna Müller Grocholski Foundation, Zürich, Switzerland generously supported this research.
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Competing interests None.
Patient consent Parental consent obtained.
Ethics approval This study was conducted with the approval of the Commission d’Ethique, Faculté de Biologie et Médecine, Lausanne University.
Provenance and peer review Not commissioned; externally peer reviewed.