Child Protection, EDS, and HSD

Signs and Symptoms in Ehlers-Danlos Syndromes

Signs of physical abuse include things like unexplained bruising, soft tissue injuries, and dislocations. These can also occur naturally to varying degrees in the different types of EDS, and to differing degrees between individuals with the same form of EDS.

In conditions like osteogenesis imperfecta, osteoporosis, and some of the more rare types of EDS, fractures can occur either spontaneously or with apparently minimal trauma. However, there is no clear evidence that fractures occur in this way in infants. There is some evidence that ambulant children with Ehlers-Danlos syndromes may be at a higher risk of common fractures (e.g. wrist) due to falls (Rolfes et al.) (An Open Letter on Ehlers-Danlos Syndromes, Child Abuse, and Bone Fractures).

There is also evidence that vascular complications such as hematoma (swelling of blood in soft tissues/skin), intracranial (internal within the skull) bleeding, and dissection (split of the lining of a blood vessel) can occur, albeit it rarely, in several of the more rare forms of EDS, and not just in the vascular form of EDS (vEDS).

(D’hondt S, Van Damme T, Malfait F, 2018 (see Table 2 and Figure 2 in particular).

However, there is no evidence in the literature that these severe vascular concerns arise in the hypermobile variant of EDS (hEDS).

In addition, there are a number of reasons why fabricated illness might be raised as a concern in children and adolescents. For example:

• symptoms or signs found on a physical examination may not be explained by any medical condition; or
• medical investigations do not explain the symptoms and signs; or
• the onset of more new symptoms after the resolution of previous ones; or
• over time there are repeated presentations with a range of signs and symptoms.

Normal daily life activities could be being affected, for example, school attendance, to an extent that seems beyond what might be expected for the medical disorder the young person is known to have.

Because this is so complex, and because welfare is of fundamental concern either way (be it abuse or a medical condition), all cases should be assessed very carefully, and all the medical possibilities considered. What is irrefutable is that with overwhelming pain and multiple symptoms both a young person and their family need dedicated multidisciplinary help.

Supporting the Assessment of a Young Person with EDS or HSD

When the explanation given does not appear to match the injury or illness found, health and social/welfare staff and law enforcement staff are obliged to report their concerns if they think someone may be a victim of abuse. These staff may or may not be familiar with conditions like EDS or HSD.

There are ways to help those assessing concerns over abuse. Some key things to consider in EDS are:

• Is there a confirmed diagnosis of EDS and how has this presented over time, as an individual? It is important to have a clear picture of the “natural history”—i.e. how the condition has affected them to date. Not everyone with EDS has the same set of concerns or severity of concerns. Is what has happened normal for them or abnormal for them? If it is abnormal, why might this have happened? Are there explanations other than abuse for the change in the pattern or type of injury or behavior?
• If either or both biological parents have EDS or a similar condition this may help to guide opinion but ultimately it is important to know whether the child or adolescent has the condition.
• Have those raising the concern consulted a professional who has experience diagnosing and treating EDS, if they do not have that expertise themselves?
• With regard to fractures, have other medical causes known to be associated with fracture been considered, and is the type of fracture a recognized or reasonably a potential complication of that condition?
• Around the world, there may be differing policies and laws when dealing with child abuse. Advice should be sought from a legal representative familiar with local policy and law.
• Whenever possible work with the health, welfare, and law enforcement staff. In doing their job they are obliged by law to report their concerns. The welfare of the young person will be at the forefront of their minds.

It is inevitable in complex cases that multi-disciplinary input is needed, but in the presence or possible presence of EDS, this should include an expert opinion in EDS and the heritable disorders of connective tissue.

For more information on fractures in childhood, please see: An Open Letter on Ehlers-Danlos Syndromes, Child Abuse, and Bone Fractures.

For more information on fabricated or induced illness, please visit nhs.uk

For more information on Safeguarding, please visit:

DCSF (2008) Safeguarding children in whom illness is fabricated or induced. Supplementary guidance to Working Together to Safeguard Children.

HM Government (2013) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London. The Stationary Office. http://bit.ly/2Fat9kH