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Dr. Amanda Brownell is a child abuse pediatrician and medical director of the Spurwink Center for Safe and Healthy Families in South Portland. She is also a clinical assistant professor at the Tufts University School of Medicine, Maine Medical Center and a member of the Maine Child Death and Serious Injury Review Panel.
If you are concerned about a child being neglected or abused, call Maine’s 24-hour hotline at 800-452-1999 or 711 to speak with a child protective specialist.
For every child abuse fatality that is publicized in the news, for every case that receives government-level reviews and public attention, we must realize there are many more children who suffer from abuse that never make the headlines. Fortunately, there is a simple, yet powerful assessment tool, known as TEN-4 that can help those caring for children identify early signs of abuse.
According to published national data, more than one in three children will have been part of a child protective investigation by the time they reach 18 years of age. More than one in 10 children will be involved in substantiated abuse. As a child abuse pediatrician, my colleagues and I care for the children in Maine suffering from abuse.
Individuals and entities who work with children and their families contemplate ways to keep children safe and prevent child abuse. Common themes for intervention arise such as identifying children in high-risk situations before the child suffers devastating trauma and attempting to reduce the risk of harm. Another possible intervention is identifying subtle signs of physical abuse earlier to allow for prompt intervention to prevent worsening or ongoing abuse.
It is the last idea, the idea of identifying sentinel injuries, that has spurred much research in the field of pediatrics and one that now has as its namesake on Oct. 4, TEN-4 Awareness Day.
In 2013, a study was published from the Medical College of Wisconsin describing 200 severely abused infants less than 12 months of age. Of these, an astounding 27.5 percent had previous injuries that medical providers should have recognized as indicative of abuse. The authors concluded that: “Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.”
Despite the published literature on sentinel injuries, missed diagnoses of abuse continue to happen. My colleagues and I see this in our clinical practice in Maine. To help medical providers more confidently identify concerning injuries in young children, a research study published in 2021 looked at over 2,000 children who underwent abuse evaluations over four years. The authors developed a validated “bruising clinical decision rule” that correctly identified most abuse victims with high a sensitivity and specificity and, just as importantly, correctly identified those who were not abused.
This tool is a simple acronym identifying concerning injuries, TEN-4-FACESp:
These are bruising of the: Trunk, Ears, Neck, Frenula of the lip, Angle of the jaw, Cheek (fleshy area), Eyelid, and Subconjunctiva (the white of the eye) in children 4 years of age and under. They also include bruises anywhere in children 4 months of age and under and bruises in a pattern such as from a hand or belt.
The authors indicated that such findings, although independently not diagnostic of abuse, warrant further evaluation such as from a child abuse pediatrician. These outward signs of potential abuse, while seemingly only minor injuries, may be the only indication that a child is in an unsafe environment.
The authors subsequently suggested that Oct. 4 (TEN-4) be identified as TEN-4 FACESp Awareness Day, suggesting implementing hospital-based child abuse awareness campaigns, pediatric abusive head trauma training, and TEN-4 media days. This year, Gov. Janet Mills and the State of Maine will recognize Oct. 4 as TEN-4 Awareness Day along with several other states.
It takes all of us to protect children and prevent ongoing abuse and potential fatalities. All those who care for children should be able to identify concerning injuries early and then take steps to prevent further abuse. In addition to reporting to Child Protective Services, these children should always be evaluated medically by the most highly trained, experienced medical provider available such as the board-certified child abuse pediatricians, including those at the Spurwink Center for Safe and Healthy Families.
