Killion CM (2017) Cultural Healing Practices that Mimic Child Abuse. Ann Forensic Res Anal 4(2): 1042.

•    Child abuse
•    Cultural healing practices
•    Immigrants
•    Ethnic minority groups
•    Differential diagnosis

Child abuse is an invisible epidemic that has serious short and long term ramifications for the affected children, their families and society at large. Making a diagnosis that suggests or confirms child abuse can be challenging because many medical conditions resemble child abuse and cultural healing practices often result in the appearance of child maltreatment. In this review several cultural healing practices are described, including coining (caogio), cupping (hijama), guasha, moxibustion, and caida de mollera. Many of these cultural approaches are ancient practices that still exist, today. Also, certain birthmarkings, (Mongolian spots) may present in a manner that suggests child abuse. To insure an accurate differential diagnosis, the importance of being culturally sensitive and aware of specific belief systems and practices of cultural groups is underscored.

Child abuse is a devastating and invisible epidemic with significant ramifications for the affected children, their families, and society at large. Short and long term physical, mental, cognitive, and developmental sequelae, with serious consequences, are involved and may even result in the death of a child [1]. Effective measures to prevent, identify, and stop child maltreatment are crucial for insuring the health and safety of vulnerable infants and children. However, making a diagnosis that suggests or confirms child abuse can be challenging. A number of physical conditions, including those that cause fractures, and disorders of cutaneous, hemorrhagic, or metabolic origins can mimic child maltreatment [2]. Moreover, certain cultural healing practices may result in the appearance of child abuse.

Undoubtedly, a diagnosis of child abuse should never be overlooked and must be reported. However, a differential diagnosis is important, to avoid misinterpretations that may result in unfortunate legal consequences [2,3]. In this review an overview is provided of commonly used cultural healing practices and related physical manifestations that often mimic child abuse. Although most of these practices have ancient origins, they are currently being used by segments of the population and include practices such as coining (caogio), spooning (guasha), cupping (hijama), moxibustion, and a range of strategies to treat sunken or fallen fontanel (caida de mollera).

During the last few decades, the volume of immigrants to the United States has grown exponentially and the immigrants’ demographic characteristics and countries of origin have changed over time. Although in the 1990s immigrants came to the United States primarily from Latin America and Europe, currently and increasingly immigrants are more likely to have origins in South and East Asia [4]. Sizable numbers are also arriving from the Caribbean, the Middle East, and Sub-Saharan Africa [4]. As immigrants become immersed in the American culture, they retain many of their cultural traditions and practices. Also, members of ethnic minority groups born in the U.S. and having a longer history and presence in the country, often engage in health practices distinct from conventional medicine in the United States [5]. Health care providers are urged to be sensitive to, and knowledgeable about, alternative health belief systems and approaches to care because some of these alternative practices may seem counter to Western medicine and/or are perceived to be potentially harmful.

Coining or caogio, is an example of an ancient healing practice still being practiced, today. This dermabrasion therapy, which involves intense rubbing of the skin, is used by Vietnamese, Cambodians, and Laotians to treat a variety of illnesses [6,7]. Although Southeast Asian cultures differ somewhat in their belief systems, their use of caogio is based on similar principles. The origin of caogio is based on Taoist philosophy which considers health to be a balance between physical, moral, and internal and external forces. According to this healing practice, there are three major causative categories of illness: physical, metaphysical, and supernatural. Maintaining harmony with nature is a central tenet [6]. Conditions that cause disease include excessive emotions, incorrect diet, or imbalance between hot and cold energies and bad wind [6,7].

The Vietnamese call wind, phong [6]. According to some, the wind can invade the body and cause a variety of illnesses including headaches, muscle aches, coughs, fevers, upper respiratory infections and sore throats [6]. To alleviate the symptoms of these illnesses, the forces are balanced by using herbal remedies and dermabrasion. Ointment or oil is applied to the skin and intensive rubbing takes place [3,6,7]. Cao gio involves creating friction on the skin to restore balance. The purpose of caogio is to release excessive air or to rub or scratch out the wind. The procedure is used on various parts of the body, though primary locations for application are the posterior thorax, shoulders, chest, temples, and forehead [6]. If the coin rubbing procedure leaves a red mark, caogiois considered to be effective. Usually, caogio results in linear erythematous patches, petechiae, or purpura [3,6,7]. Although most of the complications associated with this practice have been minor burns, a few cases of serious complications from coining have been reported requiring skin grafts when the heated oil on the skin caught fire [3]. Certainly, abuse should be suspected, if such markings are noticed on children, not from groups who traditionally use this practice. Careful history-taking and follow-up are warranted for those who have caogio applied regularly.

A practice similar to coining is spooning or guasha, which is used in China to rid the body of illness. This procedure results in a linear pattern of ecchymosis on the patient’s skin when a spoon or spoon-like tool, made of porcelain, jade, bone, horn or similar material, is used to rub the wet skin [7-9]. Skin eruptions may be generated that resemble a pine tree pattern, with long vertical marks along the spine and paralleling the ribcage as may also be seen in caogio [10] (Figure 1).

Cupping is another ancient, though fairly common practice, which has been used throughout the Middle East, Asia, Latin America, and Eastern Europe. In the United States, this technique is practiced primarily by Russian immigrants and its use has been revitalized among naturalistic health providers, as well [3,9,11]. There are two types of cupping: wet and dry [11,12]. Wet cupping, also known as hijama, involves small cuts to the skin to draw blood and is thought to help rid the body of toxins [11]. In dry cupping the air, in an open-mouthed vessel, is heated and subsequently, the vessel is applied to the skin. Suction is produced by the cooling and contracting of the heated air and is thought to “draw out” the ailment as the heated air and the rim of the cup burn the skin [11] (Figure 2). The signs of cupping usually present on the patient’s back, as multiple, grouped circular ecchymoses. Central ecchymosis or petechiae result from the suction effect of the heated air as it cools and contracts (Figure 3). Dry cupping is used to alleviate pain, primarily musculoskeletal, and inflammation. It is purported to increase blood flow and promote relaxation and well-being. Further, it is used as a type of deep tissue massage [12]. Cupping therapy is growing in popularity as an alternative treatment for a variety of conditions and diseases in patients of all ages, including athletes [12].

Another cultural healing practice is moxibustion (Figure 4). Originating in Asian medicine, this healing practice involves burning rolled pieces of moxa herb (mugwort or Artemisia vulgaris) directly over the skin above acupuncture points and allowing the herb to burn near the skin’s surface until the onset of pain [3,13]. The lesions of moxibustion appear as a pattern of “discrete circular, target-like burns” that may be confused with cigarette burns from child abuse [9]. Moxibustion is one of the most commonly used treatments in traditional medicine in East Asian cultures and is applied for a variety of symptoms, including fever and abdominal pain [3,13]. It is particularly effective in promoting energy (qi) and has been used to treat those experiencing chronic fatigue [14]. In Korea, contemporary studies indicate that moxibustion is being used in combination with conventional therapy to enhance immune functioning in children with cerebral palsy [15].

Caida de mollera (fallen fontanel), a serious infant health condition, is treated by culturally bound strategies in Mexico, Guatemala, and other Central American countries. This condition refers to the presence of a sunken anterior fontanel in an infant and is believed, in some Latin American subcultures, to cause a variety of symptoms including poor feeding, irritability and diarrhea [9,16]. The folk treatment for caida de mollera may present the physical symptoms associated with shaken baby syndrome or abusive head trauma [9,16]. Central to the concept of caida de mollera is the belief that an infant has experienced some sort of trauma resulting in a “fallen fontanel” [16]. It is important to recognize that the trauma may be unwitnessed and simply conjectured by family members or an indigenous healer, if a baby has a particular constellation of symptoms. The traumatic event may be thought to lead to organ displacement in which the movement of a body part from its proper location results in illness [16]. Specifically, the trauma is thought to force the fontanel downward, the head contents sink and the palate falls creating a bolita or bump on the roof of the mouth, obstructing the feeding process. The most commonly quoted causes in folk medicine of caida de mollera are distinct from the biomedical explanation of the resulting poor feeding, leading to dehydration, malnutrition, and a depressed fontanel [9,16]. Rather, causes of caida de mollera are attributed to the quick separation of the nipple from the mouth of a feeding baby, traveling on a bumpy road, rocking too fast, allowing the baby to suck on an empty body, and improper carrying, holding, and dressing an infant [9,17].

Attempts to correct this condition may involve oral suction over the fontanel by a curandero or folk healer, slapping of the soles of the feet of the infant, pushing upon the palate in the mouth, or shaking the infant vertically while holding the baby upside down. The shaking is usually nonviolent and generally thought not to cause significant resultant injury [3,16,17]. However delays in addressing the dehydration, the likely cause of the sunken fontanel is potentially life threatening. Although caida de mollera is an unlikely cause of shaken baby syndrome (abusive head trauma) the immediate addressing of an infant’s symptoms is imperative as an attempt is made to align biomedical approaches to care with those supportive of the lay explanatory models of healing [17]. Priorities of care include careful history taking, addressing the physical symptoms of the child and educating the parents.

Several cultural healing practices with which health providers should be familiar, have been presented. The physical manifestation of these practices may be confused with, or misinterpreted, as child abuse. Being sensitive to cultural beliefs and maintaining a nonjudgmental attitude will help in obtaining an accurate history and a careful examination, and in differentiating manifestations of cultural healing practices from signs of physical abuse. Knowledge of these cultural healing practices can facilitate a differential diagnosis, may lead to the initiation of appropriate therapy and can avert the negative consequences of an incorrect evaluation of and/or report of suspected child abuse. However, special consideration must be given when medical complications from such cultural healing practices do occur and/or if the safety of an infant or child is perceived to be in jeopardy because of these practices

Beyond the clinician making a diagnosis and advancing appropriate treatment, it is also prudent to understand why use of these ancient practices persists. The power of cultural healing practices must be acknowledged despite limited evidence of the scientific efficacy of some of these practices. Populations, that engage in alternative healing practices, often seek to connect with, and become empowered by, their cultural heritage. At the same time, they may be struggling to process the values and approaches of the dominant culture with its conventional medicine [18]. The clinician must endeavor to bridge that gap with respect and cultural sensitive.

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