Physical Abuse

Types of physical abuse

Physical abuse means deliberately hurting a child or young person. It includes:

• physical restraint; such as being tied to a bed, locked in a room
• inflicting burns
• cutting
• slapping
• punching
• kicking
• biting
• choking
• stabbing or shooting.
• withholding food or medical attention
• drugging
• denying sleep
• inflicting pain
• shaking or hitting babies
• fabricating or inducing illness (FII) (RCPCH, 2009). Occurs when a carer actively promotes the sick role of a child by exaggeration, non-treatment of real problems, fabrication (lying) or falsification of signs, and/or induction of illness.

In severe cases, some of the behaviours by a carer that may result in harm include:

• Deliberately inducing symptoms by administering medication or other substances (this includes non-accidental poisoning), or by intentional suffocation
• Interfering with treatments by over-dosing, not administering medication, or interfering with medical equipment such as infusion lines;
• Claiming the child has symptoms which are unverifiable unless observed directly, such as pain, frequent passing of urine, vomiting, or fits, resulting in unnecessary investigations and treatments;
• Exaggerating symptoms, again resulting in unnecessary investigations and treatments;
• Falsifying test results and observation charts;
• Obtaining specialist treatments or equipment for children which are not required;
• Alleging unfounded psychological illness in a child.

Possible signs and indicators

Bruises suspect child maltreatment if:

a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement.

there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable, for example, on immobile child.

Bites, lacerations (cuts), abrasions and scars suspect child maltreatment if:

there is a report or appearance of a human bite mark that is thought unlikely to have been caused by a young child.

child has lacerations, abrasions or scars and the explanation is unsuitable. Such as on areas usually protected by clothing (for example, back, chest, abdomen, axilla, genital area)

Thermal and cold injuries suspect child maltreatment if:

a child has burn or scald injuries:

• the explanation for the injury is absent or unsuitable or the child is not independently mobile or on any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, back) or* in the shape of an implement (for example, cigarette, iron) or that indicate forced immersion, for example: scalds to buttocks, perineum and lower limbs: scalds to limbs in a glove or stocking distribution
• child has cold injuries (for example, swollen, red hands or feet) with no obvious medical explanation.
• if a child presents with hypothermia and the explanation is unsuitable.

Fractures suspect child maltreatment if:

a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable. Presentations include:

• fractures of different ages
• X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants.

Intracranial injuries suspect child maltreatment if:

a child has an intracranial injury in the absence of major confirmed accidental trauma or known medical cause, in one or more of the following circumstances:

• the explanation is absent or unsuitable*
• the child is aged under 3 years
• there are also:
• retinal haemorrhages or
• rib or long bone fractures or
• other associated inflicted injuries
• there are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic ischaemic damage (damage due to lack of blood and oxygen supply) to the brain.

Eye trauma suspect child maltreatment if:

a child has retinal haemorrhages or injury to the eye in the absence of major confirmed accidental trauma or a known medical explanation, including birth related causes.

Spinal, visceral, oral and general injuries suspect physical abuse if:

a child presents with signs of a spinal injury (injury to vertebrae or within the spinal canal) in the absence of major confirmed accidental trauma. Spinal injury may present as:

• a finding on skeletal survey or magnetic resonance imaging
• cervical injury in association with inflicted head injury
• thoracolumbar injury in association with focal neurology or unexplained kyphosis (curvature or deformity of the spine).

a child has an intra-abdominal or intrathoracic injury in the absence of major confirmed accidental trauma and there is an absent or unsuitable explanation, or a delay in presentation. There may be no external bruising or other injury.

a child has an oral injury and the explanation is absent or unsuitable.

if there is no suitable explanation* for a serious or unusual injury.

Further information:

NSPCC and Cardiff University Department of Child Health. (2012a). Core Info: Bruises on Children. (Accessed 29/7/2019).

NSPCC and Cardiff University Department of Child Health. (2012b). Core Info: Fractures in Children. (Accessed 29/7/2019)

NSPCC and Cardiff University Department of Child Health. (2012d). Core Info: Oral Injuries and Bites on Children.* (Accessed 29/7/2019)

NSPCC and Cardiff University Department of Child Health. (2012e). Core Info: Thermal Injuries on Children. (Accessed 29/7/2019)

NSPCC and Cardiff University Department of Child Health. (2014a). Core Info: Head and Spinal Injuries in Children. (Accessed 29/7/2019)

Fabricated and Induced Illness a practical guide for paediatricians (Accessed 29/7/2019)

Welsh Assembly Government. Safeguarding Children in whom Illness is Fabricated or Induced – Supplementary guidance to Safeguarding Children: Working Together Under the Children Act 2004. 2008.