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Case Report

A case report for differential diagnosis: Integrative medicine vs child abuse

Cristina Silveira Ribeiro , Fernanda Rodrigues, Catarina Ribeiro, Teresa MagalhesNational Institute of Legal Medicine, Jardim Carrilho Videira, 4050-167 Porto, Portugal

a r t i c l e i n f o

Article history:Received 14 June 2010

Received in revised form 9 August 2010Accepted 12 August 2010

Keywords:Child physical abuseBruisesIntegrative medicineFolk medicineMimickersDifferential diagnosis

a b s t r a c t

The authors present the case of a ten-year-old Chinese boy who was taken to a hospital due to the pres-ence of suspicious bruises on his body. The child was examined in the National Institute ofLegal Medicine

by forensic doctors and a forensic psychologist. Clinical characteristics of the case are summarized stress-ing that a better understanding of some kinds of integrative medicine (IM) may help to differentiate inju-ries resulting from those practices. This is the only and unique case diagnosed by the medico-legalservices in Portugal.

In fact a great range of IM practice has the potential to create confusion in the diagnosis of physicalchild abuse. This study focuses on the differential diagnosis of one specic kind of frequent skin injuryusually seen in situations of both child abuse and IM (in this case Tui Na) - bruises.

As the number of people who practice Traditional Chinese Medicine and other forms of IM increases inthe Western world, the child protection community would benet from familiarizing itselves with thesepractices to prevent social and/or legal conicts that may arise from mistaken diagnoses of abuse.

The objective of this case report is to emphasize the relevance of comprehensive and interdisciplinaryevaluation of child abuse cases taking into account the specics of each case, to achieve a properdiagnosis.

2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Child abuse is a worldwide concern that is frequently under-diagnosed. Nevertheless in some cases, the authors believe thatthe lack of experience or even overzealousness can result inover-diagnosis. Both situations can be catastrophic for childrenand their families.

Physicians, as well as forensic doctors, must become skilled inrecognizing factors that place a child at risk of abuse. Thus, earlyand minor signs of abuse must be identied and reported if moreserious abuse is to be prevented [1] . However, there may be situa-tions where evidence of abuse may be difcult to interpret. So it ismandatory for medical community to be aware of mimickers of child abuse and red ags in the patients medical history [2] whenconfronted with physical examination that may suggest abuse.

The skin is the most commonly involved organ affected by acci-dental or non-accidental injury in children [3] . In cases of con-rmed physical abuse, up to 90% present skin injuries, beingbruises the most frequently found [4] . A simple injury can be animportant marker, requiring an assessment of its aetiology. Hencea methodical approach is needed to differentiate abusive cutane-ous injuries from mimickers of physical abuse [5] .

When child abuse is suspected, correct clinical approach has thefollowing three objectives [6] : (a) medical (to assess the physicaldamage to the child and develop an appropriate treatment plan);(b) psychological (to assessment as well as to provide the child asense on safety); (c) medico-legal and forensic (to provide physical,biological and psychological documentation to be used asevidence).

The simple examination of the injury does not lead directly toits aetiology. The forensic workup is straightforward when a childpresents with apparent signs of inicted injuries and/or a history of abuse [5] . Distinguishing the type of injuries, especially bruising,requires attention to the way of production, injury dating, patterns,location, number, bodily distribution, associated symptoms andcultural context. It is of the utmost importance to determine theirpossible aetiology [7,8] ; nevertheless when it comes to integrativemedicine (IM) remedies, few articles were found concerning thedifferential diagnoses for bruises [9] .

2. Case report

A ten-year-old Chinese boy was urgently referred, by his schoolteacher, to a hospital on the suspicion of physical abuse. The boypresented skin marks that were interpreted as abuse related inju-ries. According to the information provided by the school teacher,this was the third time in two years the boy presented with thiskind of signs being the case reported to the public prosecutor. A

1344-6223/$ - see front matter 2010 Elsevier Ireland Ltd. All rights reserved.doi: 10.1016/j.legalmed.2010.08.003

Corresponding author. Tel.: +351 912174712; fax: +351 222083978.E-mail address: cristirib@gmail.com (C.S. Ribeiro).

Legal Medicine 12 (2010) 316319

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forensic examination was then performed at the North Branch of the National Institute of Legal Medicine once, according to Portu-guese Criminal law, reporting is mandatory in suspected childabuse.

The boy, along with his parents and his sister (a 15-year-oldstudent) were Chinese immigrants, owned a shop and had been liv-ing in Portugal for two years. This family did not have any known

previous background of domestic violence, drug or alcohol abuse orany other risk factors.

3. Physical examination

A physical exam showed the presence of multiple circular andoval bruises on the forehead, face, chin, neck, on the back and frontof the chest and abdomen and on the upper limbs. They had a reg-ular distribution and some were symmetrically distributed with aregular pattern. All of the bruises seemed to have evolved over thesame period of time as they had almost the same colour pattern.Adhesive traces were observed on the back and front of his chest(Figs. 13 ), that had been applied by his parents in order to coverthe injuries.

Whenever a question concerning the aetiology of the lesionswas asked to the child, his answer was I dont know.

4. Psychological examination

A forensic psychology expert was then requested and this examwas conducted with the help of a medical student of Chinesenationality who could speak Portuguese as well as the same dialect

as the family. As a rst step, a family interview was done with hisparents and sister to understand the development of the boy andalso understand the familys social and cultural context, as well

Fig. 1. Multiple circular and oval bruises symmetrically distributed on the back of the chest with a regular pattern.

Fig. 2. Multiple circular and oval bruises symmetrically distributed on the front of neck, chest and upper limbs with a regular pattern.

Fig. 3. Multiple circular and oval bruises symmetrically distributed on the front of neck, chest and upper limbs with a regular pattern.

C.S. Ribeiro et al./ Legal Medicine 12 (2010) 316319 317

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as to try to obtain information regarding the marks on the body. Onthis particular point, the parents explained that the marks foundon the childs body were related with a Traditional Chinese Medi-cine (TCM) practice, which consists of pressing and pulling the skinin specic parts of the body to cure diseases. The family was verysurprised and frightened by the consequences of this practice,claiming that they do not mistreat their children. The practices de-

scribed by the parents for dealing with their childs behaviour wereglobally adequate by western stands.Cognitive evaluation was performed using scales (such as the

Wechsler scale WISC III), since there are no cognitive tests vali-dated for Chinese individuals living outside their country. These re-vealed that the child was fully oriented in time and space, was ableto follow instructions and demonstrated an adjusted/normalbehaviour (no behavioural noted). During the interview, the boywas always cooperative but showed a high level of anxiety whenfacing the possibility of being separated from his family, denyingthe hypothesis of abuse and explaining that the marks that the tea-cher saw were a result of a treatment method used in China, whichhis father usually used when he had fever.

5. Discussion

With the global movement of populations carrying along theirown culture and practices for the treatment of symptoms or ill-nesses suggests that a person, even if not in his or her own country,holds onto the techniques of his or hers original traditional culture.These practices are not generally considered abusive although theirapplication can result in injuries. Society is becoming more diverseas it has become more transient, by this trend is increasing world-wide, especially when TCM is concerned. Medical personnel mustbe aware of this issue and be prepared to make adequate differen-tial diagnoses [10,11] .

TCM has an extensive history of practical clinical experience,including a wide range of techniques with several therapeutic ap-proaches which may be associated with skin injuries as describedin Table 1 [13] :

In this case report it was found that Tui Na technique had beenused. It is a recognized form of medical treatment for a wide rangeof health problems and also a part of Chinese culture. This tech-

nique, used on the child by his parents, consists of pushing, squeez-ing, pressing, stimulating, separating, dispelling - Tui - , picking,holding, handling and massaging - Na [14] . This descriptionmatched perfectly with the type of injuries found on this child(bruises), their pattern and distribution and was thus consideredto be consistent with the explanation provided.

In cases of suspicion of child abuse, a thorough multidisciplin-

ary investigation must be performed taking always into accountthe history of the injurys mechanism of production as well asthe familys social, economic and cultural context. This kind of ap-proach is of major importance both to achieve a proper diagnosebut also to take acquaintance of even risk factors. So, proper proto-col should be followed and effective protection of the child main-tained until resolution. The forensic report, medical andpsychological, was of major importance as evidence in court. Thegoal for such report was also to minimize the need for a testimonyfrom the child so preventing secondary victimization. Photo-graphic documentation of injuries was also of major importancebecause it showed to be useful not only to document ndingsbut also to allow a second expert opinion, without subjecting thechild to another physical exam, concurring also to preventing sec-ondary victimization. Photos should always be used as an adjunctto the forensic report and never as the sole form of documentation[15] . This case was not prosecuted. It is the only one diagnosed bythe Portuguese medico-legal services, and there is no written evi-dence that a similar case has ever been convicted in court.

Thus, the consequences of the use of IM are well recognized aspotential sources of confusion with child abuse, and most authorsagree that the marks left by these practices should not be taken asintentionally abusive [9] . Differing cultural customs and child rear-ing denitions inuence the perception of abuse. The authors agreewith this point of view pointing out that being sensitive to culturalissues and having a nonjudgmental attitude will help to obtain theneeded history, and in differentiating the use of integrative reme-dies from actual abuse. In many western countries the applicationof such methods may be questionable as it is not even socially, leg-ally or medical approved raising legal and forensic issues as in thepresented case. In Portugal, IM is not yet regulated, and it is notrecognized by the Portuguese Ofcial Medical Association. This it-self may promote bias in what concerns suspicious cases.

Table 1

Traditional Chinese Medicine techniques and skin injuries.

Name Technique Rationale Skin injuries

Acupuncture Needles inserted at specic acupoints on thebody used to manipulate the vital energy or Q i.

Stimulates and strengthens the Q i using theprinciples of manual acupuncture.

Punctiforme bruises

Moxibustion Application of heat to acupoints using the herb Artemisia vulgaris (mugwort)

Warming the vital energy, Q i. Bruises, burns

Auriculotherapy Needles inserted at specic acupoints on theear (approximately 350 points.

Based on the premise that the ear is ahomunculus or inverted foetus and allstructures and organs of the body arerepresented on it. Used for a wide range of conditions.

Punctiforme bruises

Cupping Partial vacuum is created in cups usually bymeans of heat and applied to the skin. Theunderlying tissues are drawn up and bloodstasis is caused.

Treating disease by causing local congestion. Purple circular mark where the cup rim waspressed against the skin.

Tui Naa Works on the energy channels and points usingthe same principles as Acupuncture but usinghands and ngers.

Process that stimulates the ow of Qui, bloodand body uids, relieves blockages and re-establishes functioning in the body.

Multiple circular and oval bruises with regularpattern and symmetrically distribution, usuallyseemed to have evolved over the same period of time as their colour is almost the same

Chinese herbalmedicine b

On a daily prescription may have up to 20natural products and can include plants (stems,leaves, owers and roots), animal parts (such ascentipedes or sea horses) and minerals (rangingfrom pearls to amber and calcium carbonate).

None, exception made for skin signs of allergy

a

This type of massage was used in the specialty of bone setting deep manipulation. Dates from 1700 BC, where massage was particularly used to treat infants.b There are approximately 6000 products available as specied in the Pharmacopoeia of the Peoples Republic of China.

318 C.S. Ribeiro et al./ Legal Medicine 12 (2010) 316319

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Despite, Wheeler, in 1988, described the Vietnamese IM, CaoGio, as associated with possible cases of non-accidental injury,since dramatic bruising can occur with this practice. The authorsuggested that, although the intention of that treatment is to helpthe child, it should be culturally sanctioned as a form of child abuseand other strategies should be suggested to the parents [12] .

In fact, if injuries resulting from the practice of IM cause dam-

age to the health, security and well being of the child and, in addi-tion there are other therapeutic strategies, less damaging to thechild it may not be admissible that caregivers insist on using IMif those other strategies are presented; in these cases we admit thatinjuries may be considered as abusive.

References

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[2] Kos L, Shwader T. Cutaneous manifestations of child abuse. Pediatr Dermatol2006;23(4):31120.

[3] Coulter K. Bruising and skin trauma. Pediatr Rev 2000;21:345.[4] Botash AS. Child Abuse Evaluation and Treatment for Medical Providers. SUNY

Upsate Medical University, Syracuse, NY. Available from: http://

www.childabusemd.org/documentation-photographic.shtml . [accessed May09.2009].

[5] Mudd SS, Findlay JS. The cutaneous manifestations and common mimickers of physical child abuse. J Pediatr Health Care 2004;18(3):1239.

[6] Legano L, McHugh MT, MPH, et al. Child abuse and Neglect. Curr Probl PediatrAdolesc Health Care 2009;45:311131125.

[7] Manno CS. Difcult pediatric diagnosis. Bruising and bleeding. Pediatr ClinNorth Am 1991;38:63755.

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[11] Korbe M. Chinese medicine in an occidental perspective. Asian Eur J2008;6:3558.

[12] Wheeler DM, Hobbs CJ. Mistakes in diagnosing non-accidental injury: 10years experience. Br Med J 1988;296:12336.

[13] Robinson N. Integrated traditional Chinese medicine. Complement Ther ClinPract 2006;12:13240.

[14] Dune L. Integrating TUINA acupressure and traditional chinese medicineconcepts into holistic nursing practice. J Sci Healing 2006;2(6):5436.

[15] Chicago IL. Photographic documentation of child abuse: American ProfessionalSociety on the abuse of Children 1995. APSAC Practice Guidelines.

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