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Overview of Child Neglect and Abuse

by Ann S. Botash, MD

  • Some factors that contribute to child neglect and abuse are poverty, drug and alcohol abuse, mental health disorders, and single parenthood.

  • Children who are neglected or abused may appear tired or dirty or have physical injuries or emotional or mental health problems.

  • Abuse is suspected when bruises suggest that the injury was not accidental, when injuries do not match the caregiver's explanation, or sometimes when both healed and new injuries are evident.

  • Treatment of neglect and abuse includes protecting the child from further harm, counseling for parents and children, sometimes hospitalization, and often assisting the family in providing safe and appropriate care.

Children can be mistreated by having essential things withheld from them (neglect) or by having harmful things done to them (abuse). Neglect involves not meeting children's basic needs: physical, medical, educational, and emotional. Emotional neglect is a part of emotional abuse. Abuse can be physical, sexual, or emotional. The different forms of abuse sometimes occur together. Child neglect and abuse often occur together and with other forms of family violence, such as spousal abuse. In addition to immediate harm, neglect and abuse cause long-lasting problems, including mental health problems and substance abuse. Also, adults who were physically or sexually abused as children are more likely to abuse their own children.

In the United States, more than 896,000 children are neglected or abused every year, and about 1,400 of them die. Neglect is about 3 times more common than physical abuse.

Neglect and abuse result from a complex combination of individual, family, and social factors. Being a single parent, being poor, having problems with drug or alcohol abuse, or having a mental health problem (such as a personality disorder or low self-esteem) can make a parent more likely to neglect or abuse a child. Neglect is 12 times more common among children living in poverty.

Doctors and nurses are required by law to promptly report cases of suspected child neglect or abuse to a local Child Protective Services agency. Health professionals should, but are not required to, tell parents that a report is being made according to the law and that they will be contacted, interviewed, and possibly visited at their home. Depending on the circumstances, the local law enforcement agency may also be notified. Prompt reporting is also required from all people whose job places children younger than 18 in their care. Such people include teachers, child care workers, foster care providers, and police and legal services personnel. Anyone else who knows of or suspects neglect or abuse is encouraged to report it but is not required to do so.

All reported cases of child abuse are investigated by representatives of the local Child Protective Services agency, who determine the facts and make recommendations. Agency representatives may recommend social services (for the child and family members), temporary hospitalization, temporary foster care, or permanent termination of parental rights. Doctors and social workers help the representatives from the Child Protective Services agency decide what to do based on the immediate medical needs of the child, the seriousness of the harm, and the likelihood of further neglect or abuse.

Types

There are a number of different types of child neglect and abuse.

Physical Neglect

Not meeting a child's essential needs for food, clothing, and shelter is the most basic form of neglect. But there are many other forms. Parents may not obtain preventive dental or medical care for the child, such as vaccinations and routine physical examinations. Parents may delay obtaining medical care when the child is ill, putting the child at risk of more severe illness and even death. Parents may not make sure the child attends school or is privately schooled. Parents may leave a child in the care of a person who is known to be abusive, or they may leave a young child unattended.

Did You Know...

  • Neglect is 3 times more common than physical abuse.

Physical Abuse

Physically mistreating or harming a child, including inflicting excessive physical punishment, is physical abuse. Children of any age may be physically abused, but infants and toddlers are particularly vulnerable. Physical abuse is the most common cause of serious head injury in infants. In toddlers, physical abuse is more likely to result in abdominal injuries, which may be fatal. Physical abuse (including homicide) is among the 10 leading causes of death in children. Generally, a child's risk of physical abuse decreases during the early school years and increases during adolescence.

More than three fourths of perpetrators of abuse are the child’s parents. Children who are born in poverty to a young, single parent are at highest risk. Family stress contributes to physical abuse. Stress may result from unemployment, frequent moves to another home, social isolation from friends or family members, or ongoing family violence. Children who are difficult (irritable, demanding, or hyperactive) or who have special needs (developmental or physical disabilities) may be more likely to be physically abused. Physical abuse is often triggered by a crisis in the midst of other stresses. A crisis may be a loss of a job, a death in the family, or a discipline problem.

Sexual Abuse

Any action with a child that is for the sexual gratification of an adult or a significantly older child is considered sexual abuse. It includes penetrating the child's vagina, anus, or mouth; touching the child with sexual intention but without penetration (molestation); exposing the genitals or showing pornography to a child; and using a child in the production of pornography. Sexual abuse does not include sexual play. In sexual play, children who are less than 4 years apart in age view or touch each other's genital area without force or coercion.

By the age of 18, about 12 to 25% of girls and 8 to 10% of boys have been sexually abused. Most perpetrators of sexual abuse are people known by the children, commonly a stepfather, an uncle, or the mother's boyfriend. Female perpetrators are less common.

Certain situations increase the risk of sexual abuse. For example, children who have several caregivers or a caregiver with several sex partners are at increased risk. Being socially isolated, having low self-esteem, having family members who are also sexually abused, or being associated with a gang also increases risk.

Emotional Abuse

Using words or acts to psychologically mistreat a child is emotional abuse. Emotional abuse makes children feel that they are worthless, flawed, unloved, unwanted, in danger, or valuable only when they meet another person's needs.

Emotional abuse includes spurning, exploiting, terrorizing, isolating, and neglecting. Spurning means belittling the child's abilities and accomplishments. Exploiting means encouraging deviant or criminal behavior, such as committing crimes or abusing alcohol or drugs. Terrorizing means bullying, threatening, or frightening the child. Isolating means not allowing the child to interact with other adults or children. Emotionally neglecting a child means ignoring and not interacting with the child and not giving the child love and attention. Emotional abuse tends to occur over a long period of time.

Münchausen by Proxy

In this unusual type of child abuse, a caregiver, usually the mother, exaggerates, fakes, or causes an illness in the child (see see Factitious Disorder Imposed on Another).

Symptoms

The symptoms of neglect and abuse vary depending partly on the nature and duration of the neglect or abuse, on the child, and on the particular circumstances. In addition to obvious physical injuries, symptoms include emotional and mental health problems. Such problems may develop immediately or later and may persist.

Physical Neglect

Physically neglected children may appear undernourished, tired, or dirty or may lack appropriate clothing. They may frequently be absent from school. In extreme cases, children may be found living alone or with siblings, without adult supervision. Physical and emotional development may be slow. Some neglected children die of starvation or exposure.

Physical Abuse

Bruises, burns, welts, or scrapes are common signs of physical abuse. These marks often have the shape of the object used to inflict them, such as a belt or lamp cord. Cigarette or scald burns may be visible on the arms or legs. Severe injuries to the mouth, eyes, brain, or other internal organs may be present but not visible. Children may have signs of old injuries, such as broken bones, which have healed. Sometimes injuries result in disfigurement.

Toddlers who have been intentionally dunked into a hot bathtub have scald burns. These burns may be located on the buttocks and may be shaped like a doughnut. The splash of hot water may cause small burns on other parts of the body.

Infants who are shaken may have shaken baby (shaken impact) syndrome. This syndrome is caused by violent shaking, often followed by throwing the infant. Infants who are shaken may have no visible signs of injury and may appear to be sleeping deeply. This sleepiness is due to brain damage and swelling, which may result from bleeding between the brain and skull (subdural hemorrhage). Infants may also have bleeding in the retina (retinal hemorrhage) at the back of the eye. Ribs and other bones may be broken.

Children who have been abused for a long time are often fearful and irritable. They often sleep poorly. They may be depressed and anxious. They are more likely to act in violent, criminal, or suicidal ways.

Sexual Abuse

Changes in behavior are common. Such changes may occur abruptly and may be extreme. Children may become aggressive or withdrawn or develop phobias or sleep disorders. Children who are sexually abused may behave in sexual ways inappropriate for their age. Children who are sexually abused by a parent or other family member may have conflicted feelings. They may feel emotionally close to the offender, yet betrayed.

Sexual abuse may also result in physical injuries. Children may have bruises, tears, or bleeding in areas around the genitals, rectum, or mouth. Injuries in the genital and rectal areas may make walking and sitting difficult. Girls may have a vaginal discharge. A sexually transmitted disease, such as gonorrhea, chlamydial infection, or sometimes human immunodeficiency virus (HIV) infection, may be present.

Emotional Abuse:

In general, children who are emotionally abused tend to be insecure and anxious about their attachments to other people because they have not had their needs met consistently or predictably. Infants who are emotionally neglected may seem unemotional or uninterested in their surroundings. Their behavior may be mistaken for mental retardation/intellectual disability or a physical disorder. Children who are emotionally neglected may lack social skills or be slow to develop speech and language skills. Children who are spurned may have low self-esteem. Children who are exploited may commit crimes or abuse alcohol or drugs. Children who are terrorized may appear fearful and withdrawn. They may be distrustful, unassertive, and extremely anxious to please adults. They may inappropriately reach out to strangers. Children who are isolated may be awkward in social situations and have difficulty forming normal relationships. Older children may not attend school regularly or may not perform well when they do attend.

Did You Know...

  • Most victims of sexual abuse know the perpetrator.

Diagnosis

Neglect and abuse are often difficult to recognize unless children appear severely undernourished or are obviously injured or unless neglect or abuse is witnessed by other people. Neglect and abuse may not be recognized for years. There are many reasons for this difficulty. Abused children may feel that abuse is a normal part of life and may not mention it. Physically and sexually abused children are often reluctant to volunteer information about their abuse because of shame, threats of retaliation, or even a feeling that they deserve the abuse. Physically abused children often describe what happened to them if asked directly, but sexually abused children may be sworn to secrecy or so traumatized that they are not able to talk about the abuse.

When doctors suspect neglect or any type of abuse, they look for signs of other types of abuse. They also fully evaluate the physical, environmental, emotional, and social needs of the child.

Physical Neglect:

A neglected child is usually identified by health care practitioners or social workers during evaluation of an unrelated issue, such as an injury, an illness, or a behavioral problem. Doctors may notice that a child is not developing physically or emotionally at a normal rate or has missed many vaccinations or appointments. Teachers may identify a neglected child because of frequent unexplained absences from school. If neglect is suspected, doctors often check for anemia, infections, and lead poisoning, which are common among neglected children.

Physical Abuse:

Physical abuse may be suspected when an infant who is not yet walking has bruises or serious injuries. Abuse may be suspected when a toddler or older child has certain types of bruises, such as bruises on the back of the legs, buttocks, and torso. When children are learning to walk, bruises often result, but such bruises typically occur on prominent bony areas on the front of the body, such as the knees, shins, forehead, chin, and elbows.

Abuse may also be suspected when parents seem to know little about their child's health or seem unconcerned about an obvious injury. Parents who abuse their child may be reluctant to describe to the doctor or friends how an injury occurred. The description may not fit the age and nature of the injury or may change each time the story is told.

If doctors suspect physical abuse, they obtain accurate drawings and photographs of the injuries. Sometimes x-rays are taken to look for signs of previous injuries. Often, if a child is younger than 2 years, x-rays of all bones are taken to check for fractures.

Sexual Abuse:

Often, sexual abuse is diagnosed on the basis of the child's or a witness's account of the incident. However, because many children are reluctant to talk about sexual abuse, it may be suspected only because the child's behavior becomes abnormal. If a child has been sexually abused within 72 hours, doctors examine the child to collect legal evidence of sexual contact, such as swabs of body fluids and hair samples from the genital area. Photographs of any visible injuries are taken. In some communities, health care practitioners who are specially trained to evaluate sexual abuse of children perform this examination.

Emotional Abuse

Emotional abuse is usually identified during evaluation of another problem, such as poor performance in school or a behavioral problem. Children who are emotionally abused are checked for signs of physical and sexual abuse.

Treatment

A team of doctors, other health care practitioners, and social workers tries to deal with the causes and effects of neglect and abuse. The team helps family members understand the child's needs and helps them access local resources. For example, a child whose parents cannot afford health care may qualify for medical assistance from the state. Other community and government programs can provide assistance with food and shelter. Parents with substance abuse problems or mental health problems may be directed to appropriate treatment programs. Parenting programs are available in some areas.

All physical injuries and disorders are treated. Some children are hospitalized for treatment of injuries, severe undernutrition, or other disorders. Some severe injuries require surgery. Infants with shaken baby syndrome usually need to be admitted to a pediatric intensive care unit. Sometimes healthy children are hospitalized to protect them from further abuse until appropriate home care can be ensured.

Some children who have been sexually abused are given drugs to prevent sexually transmitted diseases, sometimes including HIV infection. Children who appear to be very upset need immediate counseling and support. Sexually abused children, even those who appear unaffected initially, are referred to a mental health care practitioner because long-lasting problems are common. Long-term psychologic counseling is often needed. Doctors refer children with other types of abuse for counseling if behavioral or emotional problems develop.

The goal of treatment is to return children to a safe, healthy family environment. Depending on the nature of the abuse and the abuser, children may go home with their family members or may be removed from their home and placed with relatives or in foster care. This placement is often temporary, for example, until the parents obtain housing or employment or until regular home visits by a social worker are established. In severe cases of neglect or abuse, the parents' rights may be permanently terminated. In such cases, the child remains in foster care (see see Foster Care) until the child is adopted or becomes an adult.

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