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Unintended Victims: Diagnosis & Treatment of Children of Domestic Violence
2 CEUs Unintended Victims: Diagnosis & Treatment of Children of Domestic Violence

Section 8
Selected Readings Bibliography/Authors/Instructors

CE Test | Table of Contents
| Domestic Violence CEU Courses
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Diagnosing V61.21 Physical Abuse of Child
Recognizing When a Child's Injury or Illness is Caused by Abuse

Investigators must determine whether the explanation for an injury is believable. Police should begin their investigation by asking the caretaker for an explanation of the child’s bruises or injuries. This is best done by asking the question: How did the accident happen?
All bruises must be investigated. If bruises are found on two or more planes of a child’s body, investigators should be even more suspicious.

For example, a child has bruises on his buttocks and stomach. The caretaker’s explanation is that the child fell backward in the living room of the family home. This might explain the bruises on the buttocks, but not the stomach bruises. If a discrepancy exists between the reported cause of an injury and the injuries seen, law enforcement personnel should investigate further.

They should also keep in mind the following points:
- All other children in the home should be examined for possible signs of child abuse.
- Victims of physical abuse often have been intimidated and will usually support the abuser’s version of how their injuries
occurred to avoid further injury. They also feel that the abuse was just punishment because they were bad.
- A physical examination of the child in suspected cases of maltreatment must be done and the data recorded precisely.
- Laboratory data should be obtained to support or refute the evidence of abuse.
- If the reported history of an injury or injuries changes during the course of an investigation, or if there is conflict between two adult caretakers as to the cause of injury, the likelihood of child maltreatment increases.
- The demeanor of the child’s parents or caretakers is sometimes revealing. For example, the mother’s assessment of her pregnancy, labor, and delivery will often provide an insight into her attitude about her child as well as give an indication of whether there is something about the child that is influencing her behavior.

Repetitive Accidents
Multiple bruises, wounds, abrasions, or other skin lesions in varying states of healing may indicate repetitive physical assault. Such repetitive accidents or injuries may indicate that abuse is occurring. A careful examination of the circumstances and types of injuries and an assessment of the child and family should be carried out by a professional skilled in family dynamics, usually the social worker investigating a report of suspected abuse. However, a police officer from the juvenile division may in some circumstances be responsible for this, rather than a social worker.

Cutaneous (Skin) Injuries
The most common manifestations of non-accidentally inflicted injuries are skin injuries. Several characteristics help to distinguish non-accidental skin injuries from accidental ones, including their location and pattern, the presence of multiple lesions of different ages, and the failure of new lesions to appear after hospitalization. Law enforcement personnel should be sure to obtain a complete history of all injuries from the caretaker.

Bruises are due to the leakage of blood into the skin tissue that is produced by tissue damage from a direct blow or a crushing injury. Bruising is the earliest and most visible sign of child abuse. Early identification of bruises resulting from child abuse can allow for intervention and prevent further abuse.

Bruises seen in infants, especially on the face and buttocks, are more suspicious and should be considered non-accidental until proven otherwise. Injuries to children’s upper arms (caused by efforts to defend themselves), the trunk, the front of their thighs, the sides of their faces, their ears and neck, genitalia, stomach, and buttocks are also more likely to be associated with nonaccidental injuries. Injuries to their shins, hips, lower arms, forehead, hands, or the bony prominences (the spine, knees, nose, chin, or elbows) are more likely to signify accidental injury.

Age Dating of Bruises
It is important to determine the ages of bruises to see if their ages are consistent with the caretaker’s explanation of the times of injury. Age dating of bruises can often be determined by looking at the color of the bruise. The ages and colors of bruises may therefore show if more than one injury is present. Table 1 shows the ages associated with the colors of bruises.

Determining the Age of a Bruise by its Color



Red (swollen, tender)

0-2 days

Blue, Purple

2-5 days


5-7 days


7-10 days


10-14 days

No further evidence of bruising

2-4 weeks

For example, a 2-year-old boy, not toilet trained, has several yellow-to-brown bruises on his buttocks. The caretaker’s explanation for the bruises is that the child tripped in the hallway the day before and fell on his buttocks.

This would be suspicious because:
1. Children seldom bruise their buttocks in accidental falls.
2. Bruises on the buttocks are in the primary target zone for non-accidental injury.
3. The child’s diaper (whether disposable or cloth), plastic pants, and clothing would have afforded some protection to his buttocks.
4. If the injuries causing the bruises were sustained the previous day, the bruises should be red to purple.

Bruise Configurations
Bruises will sometimes have a specific configuration. This may enable law enforcement officers to determine whether bruises are accidental or non-accidental. One of the easiest ways to identify the weapon used to inflict bruises is to ask the caretaker: How were you punished as a child? The pattern of a skin lesion may suggest the type of instrument used.

Bruise or wound configurations from objects can be divided into two main categories: those from "fixed" objects, which can only strike one of the body’s planes at a time, and those from "wraparound" objects, which follow the contours of the body and strike more than one of the body’s planes. Hands can make either kind of bruise, depending on the size of the offender’s hands and the size of the child.

Examples of fixed and wraparound objects include:
- Fixed objects: coat hangers, handles, paddles.
- Wraparound objects: belts, closed-end (looped) cords, open-end cords. (Closed-end cords leave a bruise in parallel lines; open-end cords leave a bruise in a single line.)

Natural or Normal Bruising
Injuries inflicted by human hands, feet, or teeth or those inflicted by belts, ropes, electrical cords, knives, switches, gags, or other objects will often leave telltale marks (e.g., gags may leave down-turned lesions at the corners of the mouth). These marks may also help in the investigative process. For example, the size of bite marks may help to determine the biter’s approximate age; their shape may help identify whose teeth made the marks. In some cases, however, bruises are acquired innocently, through play and accidental falls, or when a child has a defect in his or her clotting mechanism.

For example, a baby is brought to the hospital with purple bruises on several body surfaces. The parents were unable to provide an explanation other than that the baby "bruised easily." Blood tests later revealed that the baby was a hemophiliac; hemophilia is associated with bruising easily, due to blood clotting problems. There is usually a history of bruising easily in families with such inherited diseases.

Other incidents of "easy bruising" in children can be explained by a low blood platelet count. Multiple bruises can occur in children with leukemia. Diseases causing easy bruising, however, are rare, and inflicted bruises are much more common. The medical diagnosis of clotting disorders requires blood tests and interpretation of those tests by qualified physicians. Therefore, law enforcement officers should try to determine if bruises are the result of an accident or due to physical abuse.

Police must also remember never to jump to conclusions and to make a complete investigation of all aspects of suspected child abuse. However, their first duty is to secure the safety of the child quickly.

Mongolian spots (a kind of birthmark) also resemble bruises but can be distinguished by their clear-cut margins, the fact that they do not fade, and their steel gray-blue color. Mongolian spots may be found anywhere on the body (but are typically found on the buttocks and lower back). In addition, they are commonly found in African Americans, Asians, and Hispanics. Investigators should await medical reports when investigating such marks.

--Farley M.S., Robert Hugh, and Robert M. Reece M.D., "Recognizing When a Child’s Injury or Illness is Caused by Abuse", U.S. Department of Justice, 2002, http://www.ncjrs.gov/pdffiles1/ojjdp/160938.pdf

Community Resources
- National Domestic Violence Hotline 1-800-799-SAFE (7233)
Free - Confidential - 24 Hours
- National Center for Victims of Crime: Dating Violence Resource Center
- The Safe Space Helpline (888) 988-TEEN
- Teen Dating Violence 24 Hour Helpline (866) 331-9474
- Family Violence Prevention Fund

- Appelbaum, Paul S. PhD, Uyehara, Lisa A., & Elin, Mark R., Trauma and Memory, Oxford University Press: New York, 1998.

- Beck, Aaron T. MA, Prisioners of Hate, HarperCollins Publishers, Inc.: New York, 1999.

- Cantor, Dorothy, PhD & Drake, Ellen MA, Divorced Parents and Their Children, Springer Publishing Company: New York, 1997.

- Chanmugam, Amy. Social Work Expertise and Domestic Violence Fatality Review Teams. Social Work. Jan2014, Vol. 59 Issue 1, p73-80. 8p

- Davies, Jill PhD and Eleanor Lyon, Safety Planning With Battered Women, SAGE Publications: London, 1998.

- Dubenetzky, Salome. Differential Diagnosis of Anxiety Disorders. Annals of Psychotherapy & Integrative Health. Summer2013, Vol. 16 Issue 2, p40-46. 7p. 2 Color Photographs, 3 Illustrations.

- Farley M.S., Robert Hugh, and Robert M. Reece M.D., "Recognizing When a Child’s Injury or Illness is Caused by Abuse", U.S. Department of Justice, 2002, http://www.ncjrs.gov/pdffiles1/ojjdp/160938.pdf

- Finkelhor, David, Heather Turner, Richard Ormrod, and Sherry L. Hamby, Violence, Abuse, and Crime Exposure in a National Sample of Children and Youth, Pediatrics: 2009-11.

- Fischer, Kay-Laurel PhD & Michael F. McGrane, Journey Beyond Abuse, Amherst H. Wilder Foundation: Saint Paul, 1997.

- Gifford, Elizabeth V.; Tavakoli, Sara; Wang, Ruey; Hagedorn, Hildi J.; Hamlett-Berry, Kim W. Tobacco dependence diagnosis and treatment in Veterans Health Administration residential substance use disorder treatment programs. Addiction. Jun2013, Vol. 108 Issue 6, p1127-1135. 9p. 4 Charts. DOI: 10.1111/add.12105.

- Hajek, Clifford. Women being battered is terrible but can be stopped! Social Work. Apr2013, Vol. 58 Issue 2, p190-190. 3/4p. DOI: 10.1093/sw/swt010

- Hodges, William PhD, Interventions for Children of Divorce: Custody, Access, and Psychotherapy, John Wiley & Sons, Inc.: Canada, 2000.

- Hoff, Lee Ann PhD, Battered Women as Survivors, Routledge: London, 2002.

-Klein, Andrew R, Practical Implications of Current Domestic Violence Research, US Department of Justice, June 9, p1-51.

- Koerner, Naomi; Antony, Martin; Young, Lisa; McCabe, Randi. Changes in Beliefs about the Social Competence of Self and Others Following Group Cognitive-Behavioral Treatment. Cognitive Therapy & Research. Apr2013, Vol. 37 Issue 2, p256-265. 10p. 3 Charts. DOI: 10.1007/s10608-012-9472-5.

- Kolk, Bessel; Najavits, Lisa M. Interview: What is PTSD Really? Surprises, Twists of History, and the Politics of Diagnosis and Treatment. Journal of Clinical Psychology. May2013, Vol. 69 Issue 5, p516-522. 7p. DOI: 10.1002/jclp.21992.

- Landes, Sara J. The Case: Treating Jared Through Dialectical Behavior Therapy. Journal of Clinical Psychology. May2013, Vol. 69 Issue 5, p488-489. 2p. DOI: 10.1002/jclp.21984.

- Monohan, John PhD, Predicting Violent Behavior, Sage Publications, Inc.: Beverly Hills, 1999.

-Postmus, Judy L., and Darcey H. Merritt, When Child Abuse Overlaps with Domestic Violence: The factors that Influence Child Protection Workers' Beliefs, Children & Youth Services Review: 2010-03.

- Potito, Christine., Andrew Day, Ed Carson, and Patrick O’Leary, Domestic Violence and Child Protection: Partnerships and Collaboration, Australian Social Work: 2009-09.

- Schechter, S. and Edleson, J. L. (1999). Effective Intervention in Domestic Violence & Child Maltreatment Cases: Guidelines for Policy and Practice. The National Council of Juvenile and Family Court Judges.

- Stuart, Richard B. PhD, Violent Behavior: Social Learning Approaches to Prediction, Management, and Treatment, Brunner/Mazel Publishers: New York, 1998.

- Thornton, Victoria. Understanding the emotional impact of domestic violence on young children. Educational & Child Psychology. Mar2014, Vol. 31 Issue 1, p90-100. 11p. 3 Black and White Photographs, 1 Diagram.

- Trevillion, Kylee; Agnew-Davies, Roxane; Michele Howard, Louise. Healthcare professionals' response to domestic violence. Primary Health Care. Nov2013

- Triplett, Ruth; Higgins, George; Payne, Brian. Experiences of Domestic Violence as a Child and Career Choice. Journal of Family Violence. Apr2013, Vol. 28 Issue 3, p289-297. 9p. 5 Charts. DOI: 10.1007/s10896-013-9499-8

- Coordinating Author/Instructor: Tracy Appleton, LCSW, MEd

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The article above contains foundational information. Articles below contain optional updates.
This Is The Summer Of Gun Violence - July 31, 2020
Gun violence is back on the rise in North Carolina and around the country. After a lull during the stay-at-home orders, shootings surged over recent weeks.
COVID-19 Is Creating Another Public Health Crisis: Domestic Violence - April 21, 2020
The weeks of stay-at-home orders have created space for some families to spend more time together than ever before. This could mean more bonding, family meals and joyful activities. But for others it makes for a dangerous situation.
More Americans Are Killing Their Romantic Partners, With Guns - April 22, 2019
After decades of decline, the rate of Americans killing their intimate partners has seen “a sharp increase” in recent years. Data shows that uptick is exclusively due to gun-related murders. That’s according to a recent look at federal homicide data from 1976 through 2017 by two Northeastern University criminologists. Homicide rates generally, have been on the decline for decades, but buried within that downward trend, the researchers found a sudden, three year spike in homicides between romantic partners beginning in 2014. “While there has been no increase in intimate partner homicides that involve knives and beatings and poisonings and other kinds of weapons,” said the study’s co-author, Criminology Professor James Fox. “The entire increase in the last few years has been with guns.” Currently, men are much more likely to kill their female partners than the other way around. In the report, Fox wrote more than two thirds of intimate partner homicides are men killing women. Only a fifth
How A Rural NC County Worked To Help Domestic Violence Victims - November 21, 2018
July 26, 2015, is a date etched in Michelle Williams' memory forever. That's the day her sister Tracy was murdered. "Every time I tell that, I have to say the whole thing. In my head it's a news broadcast," she said. "Tracy Williams murdered by her ex-partner. At a Franklin County Food Lion parking lot. On July 26, 2015."
Domestic Violence Survivors Often Need Housing, Grant Will Offer Help In Orange County - July 19, 2018
A Chapel Hill-based nonprofit that serves victims of domestic violence and their families is planning to expand its services next year to enable survivors to get back on their feet.

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