Journal of Audiovisual Media in Medicine
ISSN: 0140-511X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ijau19
Non-accidental injury: Photography and procedures Simon L. B. Dove To cite this article: Simon L. B. Dove (1992) Non-accidental injury: Photography and procedures, Journal of Audiovisual Media in Medicine, 15:4, 138-142, DOI: 10.3109/17453059209088460 To link to this article: http://dx.doi.org/10.3109/17453059209088460
Published online: 10 Jul 2009.
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Date: 04 April 2016, At: 08:12
Journal of AudiovisualMedia in Medicine 1992; 15: 138-142
Non-accidental injury: photography and procedures
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SIMON L. B. DOVE Medical photographers have a duty to produce high quality photographs of cases involving non-accidental injuries, which may be used as evidence in a court of law. The accurate recording of these inflicted lesions can have an influential role in any evaluation of child abuse. The abused child differs from the average clinical patient in many ways. This paper examines the photographic requirements together with legal and ethical issues paying particular attention to the photography of patterns of lesions in physical abuse. The recording of signs in emotional and sexual abuse is also discussed.
‘Battered baby’ incidents have in recent years provoked substantial media coverage and public concern - for both the abused children and their parents - that has increased as the complexity of the problem is exposed. There are no reliable figures for the incidence of child abuse in the UK but it is broadly accepted to be much more common and more damaging than has ever been imagined. It seems that currently most known cases are revealed by direct reporting to an agency such as the police or social services. Voluntary organizations such as ‘Child Line’ have gone a long way towards helping children to report incidents which in the past would have gone undetected. This paper examines some of the problems associated with the photography of the battered, abused or non-accidentally injured child, including recognizing physical signs and the manner of approaching and handling a distressed child. Legal and ethical implications for the medical photographer are also discussed. This is not to be taken as a definitive guide but merely as an introduction for practising medical photographers to this aspect of clinical photography.
Simon L . B . Dove is Senior Medical Photographer at the Queen Elizabeth Hospital for Sick Children, Institute of Child Health, London.
01992 Butterworth-Heinemann Ltd 0140-51 IX/92/040138-05
Definition
A child is considered to be abused if he or she is treated by an adult in a way that is unacceptable. This will vary from country to country - children are treated differently according to different opinions of ‘socially acceptable behaviour’. It must be remembered that cultures tend to differ from city to city; moreover standards change over time for example, corporal punishment has become less acceptable in the UK over the past 10 years. There is evidence to suggest that 100 years or so ago the abuse of children was considered acceptable’ in the UK. In 1895 the Society for the Prevention of Cruelty to Children characterized many of the ways in which children were battered; with boots, pans, crockery, straps, ropes, pokers, fire and boiling water. Children found themselves in injurious roles with travelling circuses, displayed as freaks in side shows, and were put out to beg, being abused by drunks and vagrants. In spite of horrifying evidence many inquests on battered children returned a verdict of ‘natural death”. The first children’s charter appeared in 1889 - some 67 years after a similar charter was introduced aimed at protecting animals. Types of abuse
Abuse may present itself in many forms, but may be generally divided
into three broad categories: physical, emotional and sexual. Characteristic appearances of physical abuse include facial injuries, especially black eyes, finger bruises without damage to the cuticle or swelling of the skin, gripping injuries of the trunk, slapping and beating injuries to the buttocks, cigarette burns, swollen joints, scalds and burns, and retinal haemorrhages from intracranial damage. A black eye is suspect since the toddler’s fall on to a flat surface rarely causes one. Black eyes can be caused only by a round object which fits into the orbit but which is not small enough to injure the eyeball, e.g. a fist or cricket ball (Figure I ) . Photographs demonstrating this type of injury include an anteroposterior view of both eyes with a close-up view of the affected eye closed and open with lid retracted, if possible at 1:l magnification. If the eye is swollen a lateral or inferior view will demonstrate this effectively. Views of the fundus might be required to record any retinal damage. A torn frenulum of the upper lip is an important sign, requiring a thorough inspection of the mouth area. Photographs demonstrating intraoral injuries can be difficult to obtain. If the child is cooperative retractors should be used to give the best view possible. Lighting for deep intraoral views should ideally consist of a ring flash, which will give a ‘shadow free’ image. If such a unit is unavailable a single mounted flash held
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Figure 1. Anteroposterior close-up view of child with‘ black eye (colour original)
close to the lens axis, and positioned to give minimum shadow, is perfectly adequate. It is important to have a flash powerful enough to enable a small aperture to be used, as maximum depth of field is essential. When taking intraoral photographs of infants and young children it may be necessary to restrain the child’s head for a short time, usually causing the child to cry and at the same time open his mouth. It is vital at this point that the photographer uses this opportunity to obtain the required photographs - if carried out swiftly no discomfort is inflicted on the patient (from the author’s experience children of 7 years of age and over are normally able to assist with any requests from the photographer). The photographer should not assume that because the patient appears upset it will not be possible to produce the required views. Photographs can be valuable for the victim of non-accidental injury when used for medicolegal purposes and therefore where the photographs will be used for the direct benefit of the child some discomfort is justified. Recognizable visual patterns
Grasping marks occur on the limbs in cases where a child has been forcibly held down or grabbed in a violent fashion (sometimes from being swung by the limbs). These are commonly seen as a thumb mark on one side of the child’s limb with marks from the remaining four fingers clearly seen on the other. A bite from the adult human appears as an oval mark accompanied by a gap at each side. It has the appearance of two crescents and a diameter of about 4cm (Figure 2). Areas with haemorrhagic lesions will turn
Figure 2. Adult bite mark farrowed) accompanied by bruising and scratches (colour original)
Figure 3. Child‘s injury sustained by beating with a belt buckle (note clear outline of implement) (magnification I: 1) (colour original)
to bruises later3. Bruises of 3 months old and more can be detected by forensic techniques using ultraviolet photography and can then be matched with dental records of the a s s a i l a d , Common weapons used in child battering are fingers, fists, sticks or belts but other instruments are also used. When an object strikes the skin, blood is violently forced out of the surface capillaries at the site of impact, bursts the tiny capillaries, and leaves the weapon’s outline etched in red. The centre of impact remains white and the shape of the weapon may be clearly seen (Figures 3 and 4 ) . If photographed to scale the lesion can be compared with the original implement. It is important to recognize patterns in the distribution of bruises - a photograph of a group of bruises may be more telling than individual close-ups (Figure 5 ) . A child who has been subjected to manual pressure on the face can be recognized
The Journal of Audiovisual Media in Medicine 11 992) Vol. 15lNo. 4
from several yards away - the classic fingertip bruises on the face are circular, with diameter varying from 0.5 to 2.0cm. They occur in crops on the face and are frequently o f different ages, fresh ones being bluish in colour and older ones going from green-blue to a yellowish colour. The bruises are of slightly different sizes and they all appear within the skin. The overlying skin is never swollen or shiny arid the overlying cuticle is always damaged. On the forehead and cheek the bruises tend to remain distinct but those on the chin and the neck tend to merge into a single bruise5. When bruises like this first appear the first requisite is to see if they will fit the pattern of a hand. Differential diagnosis includes bruising in purpura, with an excessive reaction to minimal trauma, and in other bleeding disorders. Mongolian blue spots can be commonly mistaken for non-accidental bruising. 139
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Figure 5. Bruising pattern, child grabbed forcefully (cotour original)
Figure 4. Child's back demonstrating various lash marks (magnification x 0.36) (colour original)
These are seen in normal dark-skinned babies, appearing as bluish-black lesions, commonly found on the buttocks and lumbar areas. However, Mongolian blue spots tend to fade as the child grows older, rather than in a few weeks or months as in a case of bruising, so it can be difficult to distinguish the two in clinical photographs. The most common procedure is to have the child brought back to the casualty department after a few weeks and rephotographed: if bruising was present the original lesions would be starting to fade; Mongolian blue spots would still appear with no overall fading. When presented with a case involving burns a detailed examination of the patient is always advisable. Scalds are the most frequent cause of accidental thermal injury in children - and of child abuse cases. Agents that usually cause scalding are tea, coffee and cooking pots, usually from above. The pattern of burns can tell much about the type of injury the child has sustained, i.e. the initial impact of the hot fluid. The child 140
Figure 6. Child presenting with suspected cigarette burns to the forehead (note the circular lesions grouped together) (colour original)
who has been involved in accidental scalding usually looks up and pulls a container of hot liquid down upon himself, resulting in burns to the neck, face, arm and upper trunk6. Sparing of these areas suggests that the hot liquid was poured or thrown upon the victim. Excessive splash burns above the site of impact suggest that fluid was thrown at the victim. Patterns such as these can often be used to show the position of the victim at the time of injury. Symmetrical deep burns with crisp margins suggest that a child has been held against a wall heater, as opposed to small burn areas with slurred margins lacking a full imprint of the burning surface7. It is important to make sure that no lesions are left undocumented by the photographer - the extent of the injury should be recorded in one view and close-up views taken of any individual patterns which might help in establishing the cause of the injury. Cigarette burns are often grouped and multiple, most often involving the hands and arms, appearing as deep
circular lesions as opposed to single shallow and irregular lesions when inflicted accidentally (Figure 6). An examination of the patient by the photographer is always required, especially with cases involving burns. An important differential diagnosis is impetigo, but the cluttered lesions are of different sizes and new ones start to appear soon after treatment. Sexual abuse
Photographing the sexually abused child requires tact and understanding. With older patients (from early teens) a chaperone other than a relative, i.e. a nurse or other competent assistant, must be present. This protects the photographer from any accusations of impropriety. The psychological background of the patient may not be known so this is an important safeguard for the photographer. Severe injury to the external genitalia or anus of abused victims is comparatively rare'. Typical signs in a case of sexual abuse include Dove
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general external trauma to the genitalia, anal dilatation and torn hymen’. Photography in cases of sexual abuse is sometimes carried out at the time of the examination, perhaps at the casualty department to minimize trauma for the patient, although the photographs might be slightly inferior to those taken under studio conditions. Differential diagnosis includes lichen sclerosis, appearing as white atrophic lesions and presenting in severe cases with vulva1 soreness. When photographing the vaginal and anal areas the patient should be positioned on a white disposable sheet with legs and thighs flexed. In younger children (up to 6 years) it is preferable to allow the child to lie across the chaperone’s knee, facing forwards so that the chaperone can gently flex or abduct the child’s hips as necessary; again a white disposable sheet should be placed underneath the child to provide a suitable background. A general view is taken of the vagina showing all relevant lesions, followed by close-up views as required. It may be necessary to retract the labia majora to show the extent of the lesions; this can be performed by the chaperone using surgical examining gloves (older patients may perform this themselves). Lesions that extend into the vagina can be photographed more effectively using a speculum, which should be inserted by the examining doctor. These procedures should be carried out in the shortest possible time to avoid any prolonged discomfort to the patient. If the sexual abuse has occurred within 72h forensic tests should be sought; with appropriate samples it may be possible to confirm that abuse has indeed taken place”. O n occasion the identity of the perpetrator can be confirmed using D N A techniques. Dried semen can be seen by using a Wood’s lamp - the fluorescent semen should be easily detectable from the brilliant white patches on the skin, which can be documented using the U.V. fluorescence technique”. Emotional abuse
There is no generally agreed definition of emotional abuse, but some authorities regard a child to be abused if there is behavioural disturbance that the parents tend to ignore, and d o not seek professional help. The child normally appears dirty, poorly clothed and rather dishevelled. This type of abuse may lead to a failure to thrive, and short
stature in young children. This condition can be demonstrated by both full length (unclothed) anteroposterior and posteroanterior views, including a height scale. Close-up views of the abdomen and buttocks should be included to show wasting. Procedure
When presented with what the doctor considers to be a case of non-accidental injury it becomes that doctor’s responsibility to seek the opinion of a senior staff member; if he or she agrees that the lesions are suspicious then the parents must be informed of that suspicion. With a confirmed diagnosis it is normal procedure for the child to be admitted in order to keep the child out of any immediate danger and relieve pressure on the parents. If the parents are reluctant to allow the child to be admitted an Emergency Protection Order (which replaces the old Place of Safety Order under the Children Act 1989)’* can be obtained to keep the child in hospital. Once the child has been admitted both the casualty consultant and the social worker interview the parents. The consultant will confront the parents honestly with an assessment of the child’s injuries and how he believes they were sustained. The final diagnosis of non-accidental injury depends on a correlation between the physical signs obtained on examination, the alleged cause of the injuries and the results of investigation into the social background of the family’. It is normally at this point that the consultant requests clinical photographs to document the child’s lesions. It is helpful if the parents d o not object to this request, although unfortunately that is not always the case. While in hospital and under the care of a consultant the child’s welfare is paramount in law (The Children Act 1989)”, therefore if the consultant believes that clinical photographs of the child’s condition could be beneficial, the consultant is empowered to make such a request, with or without permission from the parents. The medical photographer carrying out the request of a consultant is thereby authorized to take such photographs. Photographing the abused patient
Clinical photographs of the abused patient are taken to record the injuries as accurately as possible. During nor-
The Journal of’Audiovisua1 Media in Medicine (1992) Vol. ISJNo. 4
mal clinical photography the photographer can use his or her skills to demonstrate texture on a particular lesion by altering the position of the key light source, for example with an oblique angle. It is important when recording non-accidental lesions to avoid using such techniques, which may exaggerate or in any way distort the appearance of the trauma. A camera motor clrive is extremely useful when photogralphing children as success depends on split-second timing. Accessory lenses should be kept to a minimum for the sake of speed and effi~iency’~.The studio must be relatively ‘child-proof‘, that is all leads should be kept clear of the floor area and any overhead cables should be kept out of arm’s reach. 11:is normal procedure for a nurse to accompany the patient to the photographic studio - in cases of non-accidental injury it is essential. O n entering the department the photographer must welcome the patient in a pleasant manner and perhaps take a few minutes to talk to him o r her. If the child is grabbed by the photographer upon entering the tlepartment the child might feel under threat, which could be distressing and certainly would not help the photographer. It is always important to explain to the child what is going to happen in language that he or she is going to understand. Talking to the child and attempting to establish some sort of relationship will go a long way towards achieving successful photographs. Under normal circumstances it is preferable to involve one of the parents in the photographic session, which is comforting for the child and usually provides the photographer with another pair of hands. With cases of abuse it is not usually possible to involve the parents, therefore a nurse or other competent assistant is required to take on a ‘motherly’ role and this in the author’s experience tends to reassure and keep the child calm. The relatively rapid onset of boredom can have an influential effect on the quality of results. Speed and the ability to keep the child’s attention are essential. It is not always possible to photograph children in the correct anatomical position - with a child of 10 years one would have more control over the positioning than with a 5-year-old child - however, it is more important to record the condition quickly with the least discomfort to the child. When it is necessary to have the patient in a state 141
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of undress, to take a full-length photograph, the patient should be allowed to dress before further views are taken, in order to prevent any unnecessary discomfort and embarrassment. The photographer may notice a particular ‘frozen look’, which is a characteristic response from a child who has suffered from abuse. The child makes no sounds - if he is a toddler he does not chatter in the presence of adults. It is worth conveying this reaction to the clinician or social workers concerned with the case. When confronted with a difficult patient who requires extensive surveillance one satisfactory slide of each view can be duplicated or printed as many times as required. However this should be avoided if possible, as a shift in colour of the duplicated slide could significantly alter the appearance of the s ~ b j e c t ’ ~In. the author’s experience it is nearly always possible to produce a complete set of photographs with the required number of views on one occasion. When photography is complete the films should be processed and printed as soon as possible. It is advisable for the photographer concerned to carry out all sorting and mounting of the photographs as it is important that no mistakes are made. Medicolegal photographs
Legal proceedings in cases of abuse may be heard in the criminal courts or in the juvenile courts - sometimes both depending on what it is expected and hoped that the case will a ~ h i e v e ’ ~ The . photographer is usually notified in the event of a particular case being brought before a court of law. Photographs brought before the courts have to be verified before they can be used as evidence’. It is normal procedure for the local police (Child Protection Team) to obtain a statement from the photographer concerned, stating that they were the photographer who took the photographs at the stated time and date and that the photographs represent a true and accurate record of the condition as seen on presentation’. It may be necessary, although only in cases where the photographs have been challenged, for the advocate to request the photographer to give evidence in person. The courts normally specify 7 x 5-inch enlargements of each view, sometimes several copies for the jury. Any specific instructions for copies and for the presentation of the photographs 142
should be closely followed by the photographer. The Protection of Children Act 1978 stipulates that it is an offence to take or distribute indecent photographs of children16. This was introduced to meet public demand for action to prevent the use of children in pornography. It must be remembered that any photographic material or visual recordings of children must leave the department in such a way that they are instantly recognized as having emanated from the department and hospital, complete with all relevant confidential labels, to include name, age, date photographed, and department record numbers. All the photographs should have the correct orientation of the subject marked clearly on the reverse. The final enlargements are bound, in order, into folders by the Child Protection Team and presented for the court at the time of the hearing. Summary
Photographing cases of child abuse is probably one of the most disturbing aspects of the medical photographer’s job. The task involves recording the child’s condition, recognizing the various patterns found in the different aspects of abuse and producing accurate clinical photographs that could be used in a court of law - photographs that could save the child from the unnecessary trauma of a repeated examination. Whether child abuse has taken place and who is responsible are legal issues for the courts to decide. A knowledge of these procedures, both practical and ethical, is vital if the photographer is going to execute his or her task effectively. Unfortunately child abuse, in one form or other, is becoming more evident every day, and non-accidental injury will remain a subject that requires the skill and tact of the medical photographer, certainly for the foreseeable future.
2. Radbill SX. Children in a world of violence. In: Helfer RE, Kemp RS, eds, The Battered Child, fourth edn. London: University of Chicago Press, 1987; 3-22. 3. Cooper C. Symptoms, signs and diagnosis of physical abuse. In: Carver V, ed, Child Abuse, A Study Text. Milton Keynes, UK: The Open University, 1980; 52-70. 4. Ruddick RF. A technique for recording bite marks for forensic studies. Medical and Biological Illustration 1974; 24: 128-9. 5. Franklin AW. A view from the accident and emergency department. In: Franklin AW, ed, Concerning ChildAbuse. Edinburgh, Scotland: Churchill Livingstone, 1975; 7-20. 6. Feldman KW. Child abuse by burning. In: Helfer RE, Kemp RS, eds, The Battered Child, fourth edn. London: University of Chicago Press, 1987; 197-211.
7. Keen JH, Lendrum J, Woolman B. Inflicted burns and scalds in children. BMJ 1975; 4: 268-9. 8. Enos WF, Conrath TB, Byer JC. Forensic evaluation of the sexually abused child. Paediatrics 1986; 78: 385-98. 9. Ricci LR. Medical forensic photography of the sexually abused child. Child Abuse Negl. 1988; 12: 305-10. 10. Royal College of Physicians. Physical Signs of Sexual Abuse in Children. A report to the Royal College of Physicians: forensic evidence. 1991; 9: 37-9.
11. Ruddick R. The role of the medical photographer in forensic medicine. Br J Photography 1982; 129: 972. 12. HMSO. The Children Act, An introductory guide for the NHS. London: HMSO, 1991; 2: 8-11.
13. Reeves C. Paediatric photography. J Audio Vis Media Med 1986: 9: 131-4.
Acknowledgements
Thanks must go to Mr J. Nayler, in the Department of Medical Illustration, Hospital for Sick Children, Great Ormond Street for his expert help and guidance in preparation of this paper.
References
1. Meadow R, ed. Epidemiology. In: ABC of child abuse, BMJ 1989; 1: 1-4.
14. Ricci LR. Photographing the physically abused child. Am J Dis Child 1991; 145: 275-81. 15. Cavenenagh W. Child abuse, a study text. Children and the Law. Milton Keynes, UK: The Open University, 1980; 146-55. 16. HMSO. The Protection of Children Act. London: HMSO, 1978. Dove
ISSN: 0140-511X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ijau19
Non-accidental injury: Photography and procedures Simon L. B. Dove To cite this article: Simon L. B. Dove (1992) Non-accidental injury: Photography and procedures, Journal of Audiovisual Media in Medicine, 15:4, 138-142, DOI: 10.3109/17453059209088460 To link to this article: http://dx.doi.org/10.3109/17453059209088460
Published online: 10 Jul 2009.
Submit your article to this journal
Article views: 37
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijau19 Download by: [RMIT University Library]
Date: 04 April 2016, At: 08:12
Journal of AudiovisualMedia in Medicine 1992; 15: 138-142
Non-accidental injury: photography and procedures
Downloaded by [RMIT University Library] at 08:12 04 April 2016
SIMON L. B. DOVE Medical photographers have a duty to produce high quality photographs of cases involving non-accidental injuries, which may be used as evidence in a court of law. The accurate recording of these inflicted lesions can have an influential role in any evaluation of child abuse. The abused child differs from the average clinical patient in many ways. This paper examines the photographic requirements together with legal and ethical issues paying particular attention to the photography of patterns of lesions in physical abuse. The recording of signs in emotional and sexual abuse is also discussed.
‘Battered baby’ incidents have in recent years provoked substantial media coverage and public concern - for both the abused children and their parents - that has increased as the complexity of the problem is exposed. There are no reliable figures for the incidence of child abuse in the UK but it is broadly accepted to be much more common and more damaging than has ever been imagined. It seems that currently most known cases are revealed by direct reporting to an agency such as the police or social services. Voluntary organizations such as ‘Child Line’ have gone a long way towards helping children to report incidents which in the past would have gone undetected. This paper examines some of the problems associated with the photography of the battered, abused or non-accidentally injured child, including recognizing physical signs and the manner of approaching and handling a distressed child. Legal and ethical implications for the medical photographer are also discussed. This is not to be taken as a definitive guide but merely as an introduction for practising medical photographers to this aspect of clinical photography.
Simon L . B . Dove is Senior Medical Photographer at the Queen Elizabeth Hospital for Sick Children, Institute of Child Health, London.
01992 Butterworth-Heinemann Ltd 0140-51 IX/92/040138-05
Definition
A child is considered to be abused if he or she is treated by an adult in a way that is unacceptable. This will vary from country to country - children are treated differently according to different opinions of ‘socially acceptable behaviour’. It must be remembered that cultures tend to differ from city to city; moreover standards change over time for example, corporal punishment has become less acceptable in the UK over the past 10 years. There is evidence to suggest that 100 years or so ago the abuse of children was considered acceptable’ in the UK. In 1895 the Society for the Prevention of Cruelty to Children characterized many of the ways in which children were battered; with boots, pans, crockery, straps, ropes, pokers, fire and boiling water. Children found themselves in injurious roles with travelling circuses, displayed as freaks in side shows, and were put out to beg, being abused by drunks and vagrants. In spite of horrifying evidence many inquests on battered children returned a verdict of ‘natural death”. The first children’s charter appeared in 1889 - some 67 years after a similar charter was introduced aimed at protecting animals. Types of abuse
Abuse may present itself in many forms, but may be generally divided
into three broad categories: physical, emotional and sexual. Characteristic appearances of physical abuse include facial injuries, especially black eyes, finger bruises without damage to the cuticle or swelling of the skin, gripping injuries of the trunk, slapping and beating injuries to the buttocks, cigarette burns, swollen joints, scalds and burns, and retinal haemorrhages from intracranial damage. A black eye is suspect since the toddler’s fall on to a flat surface rarely causes one. Black eyes can be caused only by a round object which fits into the orbit but which is not small enough to injure the eyeball, e.g. a fist or cricket ball (Figure I ) . Photographs demonstrating this type of injury include an anteroposterior view of both eyes with a close-up view of the affected eye closed and open with lid retracted, if possible at 1:l magnification. If the eye is swollen a lateral or inferior view will demonstrate this effectively. Views of the fundus might be required to record any retinal damage. A torn frenulum of the upper lip is an important sign, requiring a thorough inspection of the mouth area. Photographs demonstrating intraoral injuries can be difficult to obtain. If the child is cooperative retractors should be used to give the best view possible. Lighting for deep intraoral views should ideally consist of a ring flash, which will give a ‘shadow free’ image. If such a unit is unavailable a single mounted flash held
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Figure 1. Anteroposterior close-up view of child with‘ black eye (colour original)
close to the lens axis, and positioned to give minimum shadow, is perfectly adequate. It is important to have a flash powerful enough to enable a small aperture to be used, as maximum depth of field is essential. When taking intraoral photographs of infants and young children it may be necessary to restrain the child’s head for a short time, usually causing the child to cry and at the same time open his mouth. It is vital at this point that the photographer uses this opportunity to obtain the required photographs - if carried out swiftly no discomfort is inflicted on the patient (from the author’s experience children of 7 years of age and over are normally able to assist with any requests from the photographer). The photographer should not assume that because the patient appears upset it will not be possible to produce the required views. Photographs can be valuable for the victim of non-accidental injury when used for medicolegal purposes and therefore where the photographs will be used for the direct benefit of the child some discomfort is justified. Recognizable visual patterns
Grasping marks occur on the limbs in cases where a child has been forcibly held down or grabbed in a violent fashion (sometimes from being swung by the limbs). These are commonly seen as a thumb mark on one side of the child’s limb with marks from the remaining four fingers clearly seen on the other. A bite from the adult human appears as an oval mark accompanied by a gap at each side. It has the appearance of two crescents and a diameter of about 4cm (Figure 2). Areas with haemorrhagic lesions will turn
Figure 2. Adult bite mark farrowed) accompanied by bruising and scratches (colour original)
Figure 3. Child‘s injury sustained by beating with a belt buckle (note clear outline of implement) (magnification I: 1) (colour original)
to bruises later3. Bruises of 3 months old and more can be detected by forensic techniques using ultraviolet photography and can then be matched with dental records of the a s s a i l a d , Common weapons used in child battering are fingers, fists, sticks or belts but other instruments are also used. When an object strikes the skin, blood is violently forced out of the surface capillaries at the site of impact, bursts the tiny capillaries, and leaves the weapon’s outline etched in red. The centre of impact remains white and the shape of the weapon may be clearly seen (Figures 3 and 4 ) . If photographed to scale the lesion can be compared with the original implement. It is important to recognize patterns in the distribution of bruises - a photograph of a group of bruises may be more telling than individual close-ups (Figure 5 ) . A child who has been subjected to manual pressure on the face can be recognized
The Journal of Audiovisual Media in Medicine 11 992) Vol. 15lNo. 4
from several yards away - the classic fingertip bruises on the face are circular, with diameter varying from 0.5 to 2.0cm. They occur in crops on the face and are frequently o f different ages, fresh ones being bluish in colour and older ones going from green-blue to a yellowish colour. The bruises are of slightly different sizes and they all appear within the skin. The overlying skin is never swollen or shiny arid the overlying cuticle is always damaged. On the forehead and cheek the bruises tend to remain distinct but those on the chin and the neck tend to merge into a single bruise5. When bruises like this first appear the first requisite is to see if they will fit the pattern of a hand. Differential diagnosis includes bruising in purpura, with an excessive reaction to minimal trauma, and in other bleeding disorders. Mongolian blue spots can be commonly mistaken for non-accidental bruising. 139
Downloaded by [RMIT University Library] at 08:12 04 April 2016
Figure 5. Bruising pattern, child grabbed forcefully (cotour original)
Figure 4. Child's back demonstrating various lash marks (magnification x 0.36) (colour original)
These are seen in normal dark-skinned babies, appearing as bluish-black lesions, commonly found on the buttocks and lumbar areas. However, Mongolian blue spots tend to fade as the child grows older, rather than in a few weeks or months as in a case of bruising, so it can be difficult to distinguish the two in clinical photographs. The most common procedure is to have the child brought back to the casualty department after a few weeks and rephotographed: if bruising was present the original lesions would be starting to fade; Mongolian blue spots would still appear with no overall fading. When presented with a case involving burns a detailed examination of the patient is always advisable. Scalds are the most frequent cause of accidental thermal injury in children - and of child abuse cases. Agents that usually cause scalding are tea, coffee and cooking pots, usually from above. The pattern of burns can tell much about the type of injury the child has sustained, i.e. the initial impact of the hot fluid. The child 140
Figure 6. Child presenting with suspected cigarette burns to the forehead (note the circular lesions grouped together) (colour original)
who has been involved in accidental scalding usually looks up and pulls a container of hot liquid down upon himself, resulting in burns to the neck, face, arm and upper trunk6. Sparing of these areas suggests that the hot liquid was poured or thrown upon the victim. Excessive splash burns above the site of impact suggest that fluid was thrown at the victim. Patterns such as these can often be used to show the position of the victim at the time of injury. Symmetrical deep burns with crisp margins suggest that a child has been held against a wall heater, as opposed to small burn areas with slurred margins lacking a full imprint of the burning surface7. It is important to make sure that no lesions are left undocumented by the photographer - the extent of the injury should be recorded in one view and close-up views taken of any individual patterns which might help in establishing the cause of the injury. Cigarette burns are often grouped and multiple, most often involving the hands and arms, appearing as deep
circular lesions as opposed to single shallow and irregular lesions when inflicted accidentally (Figure 6). An examination of the patient by the photographer is always required, especially with cases involving burns. An important differential diagnosis is impetigo, but the cluttered lesions are of different sizes and new ones start to appear soon after treatment. Sexual abuse
Photographing the sexually abused child requires tact and understanding. With older patients (from early teens) a chaperone other than a relative, i.e. a nurse or other competent assistant, must be present. This protects the photographer from any accusations of impropriety. The psychological background of the patient may not be known so this is an important safeguard for the photographer. Severe injury to the external genitalia or anus of abused victims is comparatively rare'. Typical signs in a case of sexual abuse include Dove
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general external trauma to the genitalia, anal dilatation and torn hymen’. Photography in cases of sexual abuse is sometimes carried out at the time of the examination, perhaps at the casualty department to minimize trauma for the patient, although the photographs might be slightly inferior to those taken under studio conditions. Differential diagnosis includes lichen sclerosis, appearing as white atrophic lesions and presenting in severe cases with vulva1 soreness. When photographing the vaginal and anal areas the patient should be positioned on a white disposable sheet with legs and thighs flexed. In younger children (up to 6 years) it is preferable to allow the child to lie across the chaperone’s knee, facing forwards so that the chaperone can gently flex or abduct the child’s hips as necessary; again a white disposable sheet should be placed underneath the child to provide a suitable background. A general view is taken of the vagina showing all relevant lesions, followed by close-up views as required. It may be necessary to retract the labia majora to show the extent of the lesions; this can be performed by the chaperone using surgical examining gloves (older patients may perform this themselves). Lesions that extend into the vagina can be photographed more effectively using a speculum, which should be inserted by the examining doctor. These procedures should be carried out in the shortest possible time to avoid any prolonged discomfort to the patient. If the sexual abuse has occurred within 72h forensic tests should be sought; with appropriate samples it may be possible to confirm that abuse has indeed taken place”. O n occasion the identity of the perpetrator can be confirmed using D N A techniques. Dried semen can be seen by using a Wood’s lamp - the fluorescent semen should be easily detectable from the brilliant white patches on the skin, which can be documented using the U.V. fluorescence technique”. Emotional abuse
There is no generally agreed definition of emotional abuse, but some authorities regard a child to be abused if there is behavioural disturbance that the parents tend to ignore, and d o not seek professional help. The child normally appears dirty, poorly clothed and rather dishevelled. This type of abuse may lead to a failure to thrive, and short
stature in young children. This condition can be demonstrated by both full length (unclothed) anteroposterior and posteroanterior views, including a height scale. Close-up views of the abdomen and buttocks should be included to show wasting. Procedure
When presented with what the doctor considers to be a case of non-accidental injury it becomes that doctor’s responsibility to seek the opinion of a senior staff member; if he or she agrees that the lesions are suspicious then the parents must be informed of that suspicion. With a confirmed diagnosis it is normal procedure for the child to be admitted in order to keep the child out of any immediate danger and relieve pressure on the parents. If the parents are reluctant to allow the child to be admitted an Emergency Protection Order (which replaces the old Place of Safety Order under the Children Act 1989)’* can be obtained to keep the child in hospital. Once the child has been admitted both the casualty consultant and the social worker interview the parents. The consultant will confront the parents honestly with an assessment of the child’s injuries and how he believes they were sustained. The final diagnosis of non-accidental injury depends on a correlation between the physical signs obtained on examination, the alleged cause of the injuries and the results of investigation into the social background of the family’. It is normally at this point that the consultant requests clinical photographs to document the child’s lesions. It is helpful if the parents d o not object to this request, although unfortunately that is not always the case. While in hospital and under the care of a consultant the child’s welfare is paramount in law (The Children Act 1989)”, therefore if the consultant believes that clinical photographs of the child’s condition could be beneficial, the consultant is empowered to make such a request, with or without permission from the parents. The medical photographer carrying out the request of a consultant is thereby authorized to take such photographs. Photographing the abused patient
Clinical photographs of the abused patient are taken to record the injuries as accurately as possible. During nor-
The Journal of’Audiovisua1 Media in Medicine (1992) Vol. ISJNo. 4
mal clinical photography the photographer can use his or her skills to demonstrate texture on a particular lesion by altering the position of the key light source, for example with an oblique angle. It is important when recording non-accidental lesions to avoid using such techniques, which may exaggerate or in any way distort the appearance of the trauma. A camera motor clrive is extremely useful when photogralphing children as success depends on split-second timing. Accessory lenses should be kept to a minimum for the sake of speed and effi~iency’~.The studio must be relatively ‘child-proof‘, that is all leads should be kept clear of the floor area and any overhead cables should be kept out of arm’s reach. 11:is normal procedure for a nurse to accompany the patient to the photographic studio - in cases of non-accidental injury it is essential. O n entering the department the photographer must welcome the patient in a pleasant manner and perhaps take a few minutes to talk to him o r her. If the child is grabbed by the photographer upon entering the tlepartment the child might feel under threat, which could be distressing and certainly would not help the photographer. It is always important to explain to the child what is going to happen in language that he or she is going to understand. Talking to the child and attempting to establish some sort of relationship will go a long way towards achieving successful photographs. Under normal circumstances it is preferable to involve one of the parents in the photographic session, which is comforting for the child and usually provides the photographer with another pair of hands. With cases of abuse it is not usually possible to involve the parents, therefore a nurse or other competent assistant is required to take on a ‘motherly’ role and this in the author’s experience tends to reassure and keep the child calm. The relatively rapid onset of boredom can have an influential effect on the quality of results. Speed and the ability to keep the child’s attention are essential. It is not always possible to photograph children in the correct anatomical position - with a child of 10 years one would have more control over the positioning than with a 5-year-old child - however, it is more important to record the condition quickly with the least discomfort to the child. When it is necessary to have the patient in a state 141
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of undress, to take a full-length photograph, the patient should be allowed to dress before further views are taken, in order to prevent any unnecessary discomfort and embarrassment. The photographer may notice a particular ‘frozen look’, which is a characteristic response from a child who has suffered from abuse. The child makes no sounds - if he is a toddler he does not chatter in the presence of adults. It is worth conveying this reaction to the clinician or social workers concerned with the case. When confronted with a difficult patient who requires extensive surveillance one satisfactory slide of each view can be duplicated or printed as many times as required. However this should be avoided if possible, as a shift in colour of the duplicated slide could significantly alter the appearance of the s ~ b j e c t ’ ~In. the author’s experience it is nearly always possible to produce a complete set of photographs with the required number of views on one occasion. When photography is complete the films should be processed and printed as soon as possible. It is advisable for the photographer concerned to carry out all sorting and mounting of the photographs as it is important that no mistakes are made. Medicolegal photographs
Legal proceedings in cases of abuse may be heard in the criminal courts or in the juvenile courts - sometimes both depending on what it is expected and hoped that the case will a ~ h i e v e ’ ~ The . photographer is usually notified in the event of a particular case being brought before a court of law. Photographs brought before the courts have to be verified before they can be used as evidence’. It is normal procedure for the local police (Child Protection Team) to obtain a statement from the photographer concerned, stating that they were the photographer who took the photographs at the stated time and date and that the photographs represent a true and accurate record of the condition as seen on presentation’. It may be necessary, although only in cases where the photographs have been challenged, for the advocate to request the photographer to give evidence in person. The courts normally specify 7 x 5-inch enlargements of each view, sometimes several copies for the jury. Any specific instructions for copies and for the presentation of the photographs 142
should be closely followed by the photographer. The Protection of Children Act 1978 stipulates that it is an offence to take or distribute indecent photographs of children16. This was introduced to meet public demand for action to prevent the use of children in pornography. It must be remembered that any photographic material or visual recordings of children must leave the department in such a way that they are instantly recognized as having emanated from the department and hospital, complete with all relevant confidential labels, to include name, age, date photographed, and department record numbers. All the photographs should have the correct orientation of the subject marked clearly on the reverse. The final enlargements are bound, in order, into folders by the Child Protection Team and presented for the court at the time of the hearing. Summary
Photographing cases of child abuse is probably one of the most disturbing aspects of the medical photographer’s job. The task involves recording the child’s condition, recognizing the various patterns found in the different aspects of abuse and producing accurate clinical photographs that could be used in a court of law - photographs that could save the child from the unnecessary trauma of a repeated examination. Whether child abuse has taken place and who is responsible are legal issues for the courts to decide. A knowledge of these procedures, both practical and ethical, is vital if the photographer is going to execute his or her task effectively. Unfortunately child abuse, in one form or other, is becoming more evident every day, and non-accidental injury will remain a subject that requires the skill and tact of the medical photographer, certainly for the foreseeable future.
2. Radbill SX. Children in a world of violence. In: Helfer RE, Kemp RS, eds, The Battered Child, fourth edn. London: University of Chicago Press, 1987; 3-22. 3. Cooper C. Symptoms, signs and diagnosis of physical abuse. In: Carver V, ed, Child Abuse, A Study Text. Milton Keynes, UK: The Open University, 1980; 52-70. 4. Ruddick RF. A technique for recording bite marks for forensic studies. Medical and Biological Illustration 1974; 24: 128-9. 5. Franklin AW. A view from the accident and emergency department. In: Franklin AW, ed, Concerning ChildAbuse. Edinburgh, Scotland: Churchill Livingstone, 1975; 7-20. 6. Feldman KW. Child abuse by burning. In: Helfer RE, Kemp RS, eds, The Battered Child, fourth edn. London: University of Chicago Press, 1987; 197-211.
7. Keen JH, Lendrum J, Woolman B. Inflicted burns and scalds in children. BMJ 1975; 4: 268-9. 8. Enos WF, Conrath TB, Byer JC. Forensic evaluation of the sexually abused child. Paediatrics 1986; 78: 385-98. 9. Ricci LR. Medical forensic photography of the sexually abused child. Child Abuse Negl. 1988; 12: 305-10. 10. Royal College of Physicians. Physical Signs of Sexual Abuse in Children. A report to the Royal College of Physicians: forensic evidence. 1991; 9: 37-9.
11. Ruddick R. The role of the medical photographer in forensic medicine. Br J Photography 1982; 129: 972. 12. HMSO. The Children Act, An introductory guide for the NHS. London: HMSO, 1991; 2: 8-11.
13. Reeves C. Paediatric photography. J Audio Vis Media Med 1986: 9: 131-4.
Acknowledgements
Thanks must go to Mr J. Nayler, in the Department of Medical Illustration, Hospital for Sick Children, Great Ormond Street for his expert help and guidance in preparation of this paper.
References
1. Meadow R, ed. Epidemiology. In: ABC of child abuse, BMJ 1989; 1: 1-4.
14. Ricci LR. Photographing the physically abused child. Am J Dis Child 1991; 145: 275-81. 15. Cavenenagh W. Child abuse, a study text. Children and the Law. Milton Keynes, UK: The Open University, 1980; 146-55. 16. HMSO. The Protection of Children Act. London: HMSO, 1978. Dove
