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Overview of Child Maltreatment

(Child Abuse)

by Alicia R. Pekarsky, MD

Child maltreatment is behavior toward a child that is outside the norms of conduct and entails substantial risk of causing physical or emotional harm. Four types of maltreatment are generally recognized: physical abuse, sexual abuse, emotional abuse (psychologic abuse), and neglect. The causes of child maltreatment are varied and not well understood. Abuse and neglect are often associated with physical injuries, delayed growth and development, and mental problems. Diagnosis is based on history, physical examination, and sometimes laboratory tests and diagnostic imaging. Management includes documentation and treatment of any injuries and urgent physical and mental conditions, mandatory reporting to appropriate state agencies, and sometimes hospitalization and/or foster care to keep the child safe.

In 2012, 3.4 million reports of alleged child maltreatment were made to Child Protective Services in the US involving 6.3 million children. Sixty-two percent (2.1 million) of these reports were investigated in detail and about 686,000 maltreated children were identified. Both sexes are affected equally; the younger the child, the higher the rate of victimization.

About two thirds of all reports to Child Protective Services were made by professionals who are mandated to report maltreatment (eg, educators, law enforcement personnel, social services personnel, legal professionals, day care providers, medical or mental health personnel, foster care providers).

Of substantiated cases in the US in 2012, 78.3% involved neglect (including medical neglect), 18.3% involved physical abuse, 9.3% involved sexual abuse, and 8.5% involved psychologic maltreatment. Many children were victims of multiple types of maltreatment.

About 1640 children died in the US from maltreatment in 2012, about three quarters of whom were < 3 yr. Nearly 70% of these children were victims of neglect and 44% were victims of physical abuse with or without other forms of maltreatment. About 80% of perpetrators were parents acting alone or with another parent, and > 25% of child abuse fatalities were perpetrated by the mother acting alone.

Classification

Different forms of maltreatment often coexist, and overlap is considerable.

Physical abuse

Physical abuse involves a caregiver inflicting physical harm or engaging in actions that create a high risk of harm. Specific forms include shaking, dropping, striking, biting, and burning (eg, by scalding or touching with cigarettes). Abuse is the most common cause of serious head injury in infants. In toddlers, abdominal injury is common.

Infants and toddlers are the most vulnerable because the developmental stages that they may go through (eg, colic, inconsistent sleep patterns, temper tantrums, toilet training) may frustrate caregivers. This age group is also at increased risk because they cannot report their abuse. The risk declines in the early school years and increases again in adolescence.

Sexual abuse

Any action with a child that is done for the sexual gratification of an adult or significantly older child constitutes sexual abuse (see Pedophilic Disorder). Forms of sexual abuse include intercourse, which is oral, anal, or vaginal penetration; molestation, which is genital contact without intercourse; and forms that do not involve physical contact, including exposure of the perpetrator's genitals, showing sexually explicit material to a child, and forcing a child to participate in a sex act with another child or to participate in the production of sexual material.

Sexual abuse does not include sexual play, in which children close in age view or touch each other’s genital area without force or coercion. The guidelines that determine sexual abuse from play vary from state to state, but in general a difference of > 4 yr (chronologically, or in mental or physical development) is considered to be abuse.

Emotional abuse

Emotional abuse is inflicting emotional harm through the use of words or actions. Specific forms include berating a child by yelling or screaming, spurning by belittling the child’s abilities and achievements, intimidating and terrorizing with threats, and exploiting or corrupting by encouraging deviant or criminal behavior. Emotional abuse can also occur when words or actions are omitted or withheld, in essence becoming emotional neglect (eg, ignoring or rejecting children or isolating them from interaction with other children or adults).

Abuse in a medical setting

Child abuse in a medical setting (previously called Munchausen syndrome by proxy, now called see Factitious Disorder Imposed on Another) occurs when caregivers intentionally produce or falsify physical or psychologic symptoms or signs in a child. Caregivers may injure the child with drugs or other agents or add blood or bacterial contaminants to urine specimens to simulate disease. Many children receive unnecessary and harmful or potentially harmful tests and treatments.

Neglect

Neglect is the failure to provide for or meet a child’s basic physical, emotional, educational, and medical needs. Neglect differs from abuse in that it usually occurs without intent to harm. Physical neglect includes failure to provide adequate food, clothing, shelter, supervision, and protection from potential harm. Emotional neglect is failure to provide affection or love or other kinds of emotional support. Educational neglect is failure to enroll a child in school, ensure attendance at school, or provide home schooling. Medical neglect is failure to ensure that a child receives appropriate preventive care (eg, vaccinations, routine dental examinations) or needed treatment for injuries or physical or mental disorders.

Cultural factors

Severe corporal punishment (eg, whipping, burning, scalding) clearly constitutes physical abuse, but for lesser degrees of physical and emotional chastisement, the boundary between socially accepted behavior and abuse varies among different cultures. Likewise, certain cultural practices (eg, female genital mutilation [see Female Genital Mutilation]) are so extreme as to constitute abuse. However, certain folk remedies (eg, coining, cupping, irritant poultices) often create lesions (eg, bruises, petechiae, minor burns) that can blur the line between acceptable cultural practices and abuse.

Members of certain religious and cultural groups have sometimes failed to obtain life-saving treatment (eg, for diabetic ketoacidosis or meningitis), resulting in a child's death. Such failure is typically considered neglect regardless of the parents’ or caregivers’ intent. Additionally, in the US, certain people and cultural groups have increasingly been declining to have their children vaccinated, citing safety concerns (see Anti-Vaccination Movement). It is not clear whether this refusal of vaccination is true medical neglect. However, in the face of illness, refusal of scientifically and medically accepted treatment often requires further investigation and sometimes legal intervention.

Etiology

Abuse

Generally, abuse can be attributed to a breakdown of impulse control in the parent or caregiver. Several factors contribute.

Parental characteristics and personality features can play a role. The parent’s own childhood may have lacked affection and warmth, may not have been conducive to the development of adequate self-esteem or emotional maturity, and, in most cases, also included other forms of maltreatment. Abusive parents may see their children as a source of unlimited and unconditional affection and look to them for the support that they never received. As a result, they may have unrealistic expectations of what their children can supply for them, they are frustrated easily and have poor impulse control, and they may be unable to give what they never experienced. Drug or alcohol use may provoke impulsive and uncontrolled behaviors toward their children. Parental mental disorders also increase the risk of maltreatment.

Irritable, demanding, or hyperactive children may provoke parents’ tempers, as may developmentally or physically disabled children, who often are more dependent than a typically developing child. Sometimes strong emotional bonds do not develop between parents and children. This lack of bonding occurs more commonly with premature or sick infants separated from parents early in infancy or with biologically unrelated children (eg, stepchildren), increasing the risk of abuse.

Situational stress may precipitate abuse, particularly when emotional support of relatives, friends, neighbors, or peers is unavailable.

Physical abuse, emotional abuse, and neglect are associated with poverty and lower socioeconomic status. However, all types of abuse, including sexual abuse, occur across the spectrum of socioeconomic groups. The risk of sexual abuse is increased in children who have several caregivers or a caregiver who has several sex partners.

Neglect

Neglect usually results from a combination of factors such as poor parenting, poor stress-coping skills, unsupportive family systems, and stressful life circumstances. Neglect often occurs in impoverished families experiencing financial and environmental stresses, particularly those in which parents also have mental disorders (typically depression, bipolar disorder, or schizophrenia), abuse drugs or alcohol, or have limited intellectual capacity. Children in single-parent families may be at risk of neglect due to a lower income and fewer available resources.

Symptoms and Signs

Symptoms and signs depend on the nature and duration of the abuse or neglect.

Physical abuse

Skin lesions are common and may include

  • Handprints or oval fingertip marks caused by slapping or grabbing and shaking

  • Long, bandlike ecchymoses caused by belt whipping

  • Narrow arcuate bruises caused by extension cord whipping

  • Multiple small round burns caused by cigarettes

  • Symmetric scald burns of upper or lower extremities or buttocks caused by intentional immersion

  • Bite marks

  • Thickened skin or scarring at the corners of the mouth caused by being gagged

  • Patchy alopecia, with varying hair lengths, caused by hair pulling

However, more commonly, skin findings are subtle (eg, a small bruise, petechiae on the face and/or neck).

Fractures frequently associated with physical abuse include rib fractures, vertebral fractures, long bone and digit fractures in nonambulatory children, and metaphyseal fractures; in children < 1 yr, about 75% of fractures are inflicted by others.

Confusion and localizing neurologic abnormalities can occur with CNS injuries. Lack of visible head lesions does not exclude traumatic brain injury, particularly in infants subjected to violent shaking. These infants may be comatose or stuporous from brain injury yet lack visible signs of injury (with the common exception of retinal hemorrhage) or they may present with nonspecific signs such as fussiness and vomiting. Traumatic injury to organs within the chest or abdominal/pelvic region may also occur without visible signs.

Children who are frequently abused are often fearful and irritable and sleep poorly. They may have symptoms of depression (see Depressive Disorders in Children and Adolescents), posttraumatic stress reactions (see Acute and Posttraumatic Stress Disorders (ASD and PTSD) in Children and Adolescents), or anxiety (see Overview of Anxiety Disorders in Children and Adolescents). Violent or suicidal behavior may occur.

Pearls & Pitfalls

  • Lack of visible head lesions does not exclude traumatic brain injury.

Sexual abuse

In most cases, children do not spontaneously disclose sexual abuse and rarely exhibit behavioral or physical signs of sexual abuse. If a disclosure is made, it is generally delayed, sometimes days to years. In some cases, abrupt or extreme changes in behavior may occur. Aggressiveness or withdrawal may develop, as may phobias or sleep disturbances. Some sexually abused children act in ways that are sexually inappropriate for their age.

Physical signs of sexual abuse that involves penetration may include

  • Difficulty in walking or sitting

  • Bruises or tears around the genitals, anus, or mouth

  • Vaginal discharge, bleeding, or pruritus

Other manifestations include a sexually transmitted infection, and pregnancy. Within a few days of the abuse, examination of the genitals, anus, and mouth may be normal or may show healed lesions or subtle changes.

Emotional abuse

In early infancy, emotional abuse may blunt emotional expressiveness and decrease interest in the environment. Emotional abuse commonly results in failure to thrive and is often misdiagnosed as intellectual disability or physical illness. Delayed development of social and language skills often results from inadequate parental stimulation and interaction. Emotionally abused children may be insecure, anxious, distrustful, superficial in interpersonal relationships, passive, and overly concerned with pleasing adults. Children who are spurned may have very low self-esteem. Children who are terrorized or threatened may seem fearful and withdrawn. The emotional effect on children usually becomes obvious at school age, when difficulties develop in forming relationships with teachers and peers. Often, emotional effects are appreciated only after the child has been placed in another environment or after aberrant behaviors abate and are replaced by more acceptable behaviors. Children who are exploited may commit crimes or abuse alcohol or drugs.

Neglect

Undernutrition, fatigue, poor hygiene, lack of appropriate clothing, and failure to thrive (see Failure to Thrive (FTT)) are common signs of inadequate provision of food, clothing, or shelter. Stunted growth and death resulting from starvation or exposure to extremes in temperature or weather may occur. Neglect that involves inadequate supervision may result in preventable illness or injury.

Diagnosis

  • High index of suspicion (eg, for history that does not match physical findings or for atypical injury patterns)

  • Supportive, open-ended questioning

  • Sometimes imaging and laboratory tests

  • Reporting to authorities for further investigation

Evaluation of injuries and nutritional deficiencies is discussed elsewhere in T he M anual . Recognizing maltreatment as the cause can be difficult, and a high index of suspicion must be maintained. Because of social biases, abuse is considered less often in children living in a 2-parent household with a median-level income; child abuse can occur regardless of family composition or socioeconomic status.

Sometimes direct questions provide answers. Children who have been maltreated may describe the events and the perpetrator, but some children, particularly those who have been sexually abused, may be sworn to secrecy, threatened, or so traumatized that they are reluctant to speak about the abuse (and may even deny abuse when specifically questioned). A medical history including a history of the events should be obtained from children and their caregivers in a relaxed environment. Open-ended questions (eg, “Can you tell me what happened?”) are particularly important in these cases because yes-or-no questions (eg, “Did daddy do this?”, “Did he touch you here?”) can easily sculpt an untrue history in young children.

Examination includes observation of interactions between the child and the caregivers whenever possible. Documentation of the history and physical examination should be as comprehensive and accurate as possible, including recording of exact quotes from the history and photographs of injuries.

Often it is unclear after the initial evaluation whether abuse occurred. In such cases, the mandatory reporting requirement of suspected abuse allows appropriate authorities and social agencies to investigate; if their evaluation confirms abuse, appropriate legal and social interventions can be done.

Physical abuse

Both history and physical examination provide clues suggestive of maltreatment.

Features suggestive of abuse in the history are

  • Parental reluctance or inability to give a history of injury

  • History that is inconsistent with the injury (eg, bruises on the backs of the legs attributed to a fall) or apparent stage of resolution (eg, old injuries described as recent)

  • History that varies depending on the information source or over time

  • History of injury that is incompatible with the child’s stage of development (eg, injuries ascribed to rolling off a bed in an infant too young to roll over, or to a fall down stairs in an infant too young to crawl)

  • Inappropriate response by the parents to the severity of the injury—either overly concerned or unconcerned

  • Delay in seeking care for the injury

Major indicators of abuse on examination are

  • Atypical injuries

  • Injuries incompatible with stated history

Childhood injuries resulting from falls are typically solitary and occur on the forehead, chin, or mouth or extensor surfaces of the extremities, particularly elbows, knees, forearms, and shins. Bruises on the back, buttocks, and the back of the legs are extremely rare from falls. Fractures, apart from clavicular fracture, tibial (toddler’s) fractures, and distal radius (Colles) fracture, are less common in typical falls during play or down stairs. No fractures are pathognomonic of abuse, but classic metaphyseal lesions, rib fractures (especially posterior and 1st rib), and depressed or multiple skull fractures (caused by apparently minor trauma), scapular fractures, sternal fractures, and spinous processes fractures should raise concern for abuse.

Physical abuse should be considered when an infant who is not walking has a serious injury. Young infants with minor injuries to the face also should be further evaluated. The younger infant may appear to be normal despite significant brain trauma, and inflicted acute head trauma should be part of the differential diagnosis of every lethargic infant. Other hints are multiple injuries at different stages of resolution or development; cutaneous lesions with patterns suggestive of particular sources of injury (see Child Maltreatment:Physical abuse); and repeated injury, which is suggestive of abuse or inadequate supervision.

A dilated eye examination and neuroimaging are recommended for all children < 1 yr with suspected abuse. Retinal hemorrhages occur in 85 to 90% of cases of abusive head trauma vs < 10% of cases of accidental head trauma. They also may result from childbirth and persist for up to 4 wk. When retinal hemorrhages result from accidental trauma, the mechanism is usually obvious and life-threatening (eg, major motor vehicle crash), and the hemorrhages are typically few in number and confined to the posterior poles.

Children < 36 mo (previous recommendation 24 mo) with possible physical abuse should undergo a skeletal survey for evidence of previous bony injuries (fractures in various stages of healing or subperiosteal elevations in long bones). Surveys are sometimes done on children aged 3 to 5 yr but are generally not helpful for those > 5 yr. The standard survey includes images of the

  • Appendicular skeleton: Humeri, forearms, hands, femurs, lower legs and feet

  • Axial skeleton: Thorax (including oblique views), pelvis, lumbosacral spine, cervical spine, and skull

Physical disorders causing multiple fractures include osteogenesis imperfecta (see Osteogenesis Imperfecta) and congenital syphilis (see Congenital Syphilis).

Sexual abuse

Sexually transmitted infections in a child < 12 yr should make practitioners extremely suspicious about the possibility of sexual abuse. When a child has been sexually abused, behavioral changes (eg, irritability, fearfulness, insomnia) may be the only clues initially. If sexual abuse is suspected, the perioral and anal areas and the external genitals must be examined for evidence of injury. If the suspected abuse is thought to have occurred recently (≤ 96 h), forensic evidence should be gathered using an appropriate kit and handled according to required legal standards (see Testing and evidence collection). An examination involving use of a magnifying light source with a camera, such as with a specially equipped colposcope, may be helpful to the examiner as well as for documentation for legal purposes.

Emotional abuse and neglect

Evaluation focuses on general appearance and behavior to determine whether the child is failing to develop normally. Teachers and social workers are often the first to recognize neglect. The physician may notice a pattern of missed appointments and vaccinations that are not up-to-date. Medical neglect of life-threatening, chronic diseases, such as asthma or diabetes, can lead to a subsequent increase in office or emergency department visits and poor adherence with recommended treatment regimens.

Treatment

  • Treatment of injuries

  • Creation of a safety plan

  • Family counseling and support

  • Sometimes removal from the home

Treatment first addresses urgent medical needs (including possible sexually transmitted infections) and the child’s immediate safety. Referral to a pediatrician specializing in child abuse should be considered. In both abuse and neglect situations, families should be approached in a helping rather than a punitive manner.

Immediate safety

Physicians and other professionals in contact with children (eg, nurses, teachers, day care workers, police) are mandated reporters who are required by law in all states to report incidents of suspected abuse or neglect ( see US Dept of Health and Human Services, Mandated Reporting ). Every state has its own laws. Members of the general public are encouraged, but not mandated, to report suspected abuse. Any person who makes a report of abuse based on reasonable cause and in good faith is immune from criminal and civil liability. A mandated reporter who fails to make a report can be subject to criminal and civil penalties. The reports are made to Child Protective Services or another appropriate child protection agency. In most situations, it is appropriate for professionals to tell caregivers that a report is being made pursuant to the law and that they will be contacted, interviewed, and likely visited at their home. In some cases, the professional may determine that informing the parent or caregiver before police or other agency assistance is available creates greater risk of injury to the child and/or themselves. Under those circumstances, the professional may choose to delay informing the parent or caregiver.

Representatives of child protective agencies and social workers can help the physician determine likelihood of subsequent harm and thus identify the best immediate disposition for the child. Options include

  • Protective hospitalization

  • Placement with relatives or in temporary housing (sometimes a whole family is moved out of an abusive partner’s home)

  • Temporary foster care

  • Going home with prompt social service and medical follow-up

The physician plays an important role in working with community agencies to advocate for the best and safest disposition for the child. Healthcare professionals in the US are often asked to write an impact statement, which is a letter typically addressed to a Child Protective Services worker (who can then bring it to the attention of the judicial system), about a child who is suspected to be the victim of maltreatment. The letter should contain a clear explanation of the history and physical examination findings (in layman's terms) and an opinion as to the likelihood that the child was maltreated.

Follow-up

A source of primary medical care is fundamental. However, the families of abused and neglected children frequently relocate, making continuity of care difficult. Broken appointments are common; outreach and home visits by social workers and/or public health nurses may be helpful A local child advocacy center can help community agencies, health care practitioners, and the legal system work together as a multidisciplinary team in a more coordinated, child-friendly, and effective manner.

A close review of the family setting, prior contacts with various community service agencies, and the caregivers’ needs is essential. A social worker can conduct such reviews and help with interviews and family counseling. Social workers also provide tangible assistance to the caregivers by helping them obtain public assistance, child care, and respite services (which can decrease stress for caregivers). They can also help to coordinate mental health services for caregivers. Periodic or ongoing social work contact usually is needed.

Parent-aide programs, which employ trained nonprofessionals to support abusive and negligent parents and provide an example of appropriate parenting, are available in some communities. Other parent support groups also have been successful.

Sexual abuse may have lasting effects on the child’s development and sexual adaptation, particularly among older children and adolescents. Counseling or psychotherapy for the child and the adults concerned may lessen these effects. Physical abuse, particularly significant head trauma, also can have long-lasting effects on development. If physicians or caregivers are concerned that children have a disability or delayed development, they may request an evaluation from their state's Early Intervention system (see National Dissemination Center for Children with Disabilities ), which is a program to evaluate and treat children with suspected disabilities or developmental delays.

Removal from the home

Although emergency temporary removal from the home until evaluation is complete and safety is ensured is sometimes done, the ultimate goal of Child Protective Services is to keep children with their family in a safe, healthy environment. Often, families are offered services to rehabilitate the caregivers so that children who have been removed may be reunited with their family. If the previously described interventions do not ensure safety, consideration must be made for long-term removal and possibly termination of parental rights. This significant step requires a court petition, presented by the legal counsel of the appropriate welfare department. The specific procedure varies from state to state but usually entails family court testimony by a physician. When the court decides in favor of removing the child from the home, a disposition is arranged, typically to a temporary placement, such as foster care. While the child is in temporary placement, the child's own physician or a medical team that specializes in children in foster care should, if possible, maintain contact with the parents and ensure that adequate efforts are being made to help them. Occasionally, children are re-abused while in foster care. The physician should be alert to this possibility. As the dynamics of the family setting improve, the child may be able to return to the original caregivers. However, recurrences of maltreatment are common.

Prevention

Prevention of maltreatment should be a part of every well-child office visit through education of parents, caregivers, and children and identification of risk factors. At-risk families should be referred to appropriate community services.

Parents who were victims of maltreatment are at increased risk of abusing their own children. These parents often verbalize anxiety about their abusive background and are amenable to assistance. First-time parents and teenage parents as well as parents with several children < 5 yr are also at increased risk of abusing their children. Often, maternal risk factors for abuse are identified prenatally (eg, a mother who does not seek prenatal care, smokes, abuses drugs, or has a history of domestic violence). Medical problems during pregnancy, delivery, or early infancy that may affect the mother's and/or infant's health can weaken parent-infant bonding (see also Caring for Sick Neonates). During such times it is important to elicit the parents’ feelings about themselves and the infant’s well-being. How well can they tolerate an infant with many needs or health demands? Do the parents give moral and physical support to each other? Are there relatives or friends to help in times of need? The health care practitioner who is alert to clues and able to provide support can make a major impact on the family and possibly prevent child maltreatment.

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