Every year on October 4, health care organizations around the United States recognize TEN-4 Day, a movement to raise awareness about child abuse. TEN-4-FACESp is an acronym to help medical professionals screen a child under 4 years of age for bruising patterns that may be more likely due to physical abuse than accidental injury.

TEN-4-FACESp – a clinical decision rule developed and validated by experts at Ann & Robert H. Lurie Children’s Hospital of Chicago – focuses on bruises to the torso, ears and neck (TEN), and the frenulum (the tissue that runs in a thin line between the lips and gums), angle of the jaw, cheeks, eyelids and subconjunctivae (the white part of the eyes), – the FACES. The number 4 represents infants 4 months and younger with any bruise, anywhere, and “p” represents the presence of patterned bruising. The tool is to help highlight areas that are more prone to physical abuse, if there is not a good history or mechanism to explain the injury.

Graphic illustrating the parts of TEN-4-FACESp.

“Bruising is the most common and most visible sign of physical abuse. In toddlers and pre-school aged children, bruises are common. However, the location of the bruise can be helpful to distinguish accidental injuries from ones caused by physical abuse,” says Wee-Jhong Chua, MD, a physician in the Pediatric Emergency Department at Mass General for Children. “Having a tool to help identify concerning bruises for physical abuse is an important step in early recognition, which can lead to interventions before the abuse escalates to permanent injury or even death.”

In the United States, one in seven children experience child abuse or neglect. Every day in the United States, four children die because of child abuse. Three out of four of those children are under the age of four. In Massachusetts, more than 1,6000 abuse cases were reported in 2021. With support from leaders at Mass General for Children, Boston Children’s Hospital and The Children’s’ Trust, a community-based program that helps parents build the necessary skills and confidence to make sure kids have safe and healthy childhoods, Governor. Maura Healey proclaimed October 4, 2023, as TEN-4 Day in the Commonwealth to stress the importance of recognizing concerning bruising and injuries on infants and young children and to keep nonaccidental injury at the forefront of each person’s mind when interacting with or treating injured children.

“As physicians and health care providers, we are keenly positioned to recognize and report abuse. These injuries – and the potential lifelong physical and mental damage caused by them – are preventable. I’m pleased to see MGfC’s efforts to bring awareness to TEN-4 Day in Massachusetts and proud of our work to protect children every day,” says Joanne Wolfe, MD, physician-in-chief at Mass General for Children and chair of Pediatrics at Brigham and Women’s Hospital. Anyone concerned that a child is being abused can file a report with the Massachusetts Department of Children and Families (DCF). All medical personnel, school staff and first responders, amongst others, are required by law to report suspected cases of abuse and should follow the below steps if concerning bruising is found on a child:

  • Document: Take photos of the injuries. Bruises can change and fade quickly, so taking photos early and in different lighting and angles can be helpful to health care providers
  • Medical evaluation: Bring the child to their primary care provider or the local emergency room
  • Make a report: Suspected cases can be reported to the Mass DCF. Reports can be filed online at https://www.mass.gov/how-to/report-child-abuse-or-neglect or by calling the Child-at-Risk Hotline at 800-792-5200