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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 and physical examination. Management includes documentation and treatment of any injuries and urgent physical and mental conditions, mandatory reporting to appropriate state agencies, and sometimes hospitalization or other steps such as foster care to keep the child safe.
In 2007, 3.2 million cases of child abuse and neglect were reported in the US, and about 750,000 of these were substantiated. Both sexes are affected equally; the younger the child, the higher the rate of victimization.
More than half 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 2007, 59.9% involved neglect (including medical neglect); 10.8% involved physical abuse; 7.6% involved sexual abuse; and 4.2% involved psychologic maltreatment. In addition, 4.2% experienced other types of maltreatment, such as abandonment and congenital drug addictions. Many children were victims of multiple types of maltreatment.
About 1760 children died in the US from maltreatment in 2007, about three quarters of whom were < 4 yr. One third of the deaths were attributed to neglect. In substantiated cases of abuse or neglect in 2007, > 80% of perpetrators were parents; 56.5% of perpetrators were women.
Classification
Different forms of abuse often coexist, and overlap is considerable.
Physical abuse
Physical abuse is 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 (perhaps because perpetrators know they cannot complain), with risk declining in the early school years and increasing again in adolescence.
Medical child abuse (previously called Munchausen syndrome by proxy) is discussed in Somatoform and Factitious Disorders: Munchausen Syndrome by Proxy.
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 Sexuality and Sexual Disorders: Pedophilia). Forms of sexual abuse include intercourse, which is oral, anal, or vaginal penetration; molestation, which is genital contact without intercourse; and nonspecific forms, which do not involve physical contact, including exposure, showing sexual material to a child, and forcing a child to participate in a sex act with another child or to participate in the making of sexual material.
Sexual abuse does not include sexual play, in which children close in age (typically considered < 4 yr apart) view or touch each other's genital area without force or coercion.
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).
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 Child Maltreatment: Female Genital Mutilation]) are so extreme as to constitute abuse. However, certain folk remedies (eg, coining, cupping, irritant poultices) often create lesions (eg, bruises, minor burns) that can mimic those caused by abuse; in such cases, the line between acceptable cultural practices and abuse may be blurred.
Similarly, failing to obtain life-saving treatment (eg, for diabetic ketoacidosis or meningitis) or failing to take children for any routine medical care is considered neglect whatever the parents' or caregivers' intent. However, in the US, certain people and cultural groups have increasingly been declining vaccination of their children, citing safety concerns. It is not clear whether this refusal of vaccination is true medical neglect; it may be considered similar to refusal of non life-saving treatments for religious reasons. In such cases, as long as the children are healthy, there is usually no need to ascertain whether the refusal constitutes 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 abuse. 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 lose 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 may also increase the risk of abuse.
Irritable, demanding, or hyperactive children may provoke parents' tempers, as may developmentally or physically disabled children, who often are more dependent. Sometimes strong emotional ties do not develop between parents and 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 with 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 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 or 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; and thickened skin or scarring at the corners of the mouth caused by being gagged. Patchy alopecia, with varying hair lengths, can result from hair pulling.
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). Traumatic injury to organs within the chest or abdominal 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, post-traumatic stress reactions (see Anxiety Disorders: Posttraumatic Stress Disorder), or anxiety. Violent or suicidal behavior may occur.
Sexual abuse
In most cases, children do not freely 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, rectum, or mouth; vaginal discharge, bleeding, or pruritus; or a sexually transmitted disease. Within a few days of the abuse, examination of the genitals, rectum, or mouth may be normal or may show healed lesions or subtle hymen 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, lack of hygiene or appropriate clothing, and failure to thrive are common signs of inadequate provision of food, clothing, or shelter. Stunted growth and death resulting from starvation or exposure may occur. Neglect that involves inadequate supervision may result in preventable illness or injury.
Diagnosis
Evaluation of injuries and nutritional deficiencies is discussed elsewhere in The Manual. 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 (and may even deny abuse when specifically questioned). Children should be interviewed alone and in a relaxed manner, with open-ended questions (eg, “Tell me what happened”); 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 possible perpetrators 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.
Sometimes 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 in depth; 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
Major indicators of abuse on examination are
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.
Physical abuse should be considered when an infant who is not walking has a serious injury. Young infants with minor injuries to the face should be further evaluated. The younger infant may appear to be perfectly normal or sleeping despite significant brain trauma, and inflicted acute head trauma in infants 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 specific for particular sources of injury; and repeated injury, which is suggestive of abuse or inadequate supervision.
A dilated eye examination may be useful in children < 1 yr with suspected abuse. Retinal hemorrhage occurs in 65 to 95% of cases of abusive head trauma vs < 10% of cases of accidental head trauma. It 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 pole.
Children < 2 yr 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 2 to 5 yr but are generally not helpful for those > 5 yr. The standard survey includes anteroposterior (AP) views of the skull and chest, lateral views of the spine and long bones, AP views of the pelvis, and AP and oblique views of the hands. Physical disorders causing multiple fractures include osteogenesis imperfecta and congenital syphilis.
Sexual abuse
Sexually transmitted disease of any sort in a child < 12 yr must be considered the result of sexual abuse until proved otherwise. 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 rectal areas and the external genitals must be examined for evidence of injury. If the suspected abuse is thought to have occurred recently, hair samples and swabs of body fluids are obtained for legal evidence (see Medical Examination of the Rape Victim: 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 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 drug regimens.
Treatment
Treatment first addresses urgent medical needs (including possible sexually transmitted diseases) and the child's immediate safety. Referral to a pediatrician specializing in child abuse should be considered. Ultimately, treatment is directed at long-standing disturbed patterns of personal interaction. 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 required by law in all states to report incidents of suspected abuse or neglect. 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 parents that a report is being made pursuant to the law and that they will be contacted, interviewed, and possibly visited at their home. In some cases, the professional may determine that informing the parent before police or other agency assistance is available creates greater risk of injury to the child. 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
The physician plays an important role in working with community agencies to advocate for the best and safest disposition for the child.
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 or a public health nurse may be needed to relay the child's progress to all concerned. 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 parents' 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 parents by helping them obtain public assistance and day care and homemaker services (which can relieve a parent under stress, allowing a few hours each day for relaxation) and coordinating mental health services for parents. Periodic or ongoing social work contact usually is needed.
Parent-aide programs, which employ trained nonprofessionals to relate closely to abusive and negligent parents, 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.
Removal from the home
Although emergency temporary removal from the home until evaluation is complete and safety is ensured is not uncommon, the ultimate goal of Child Protective Services is to keep children with their family in a safe, healthy environment. 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. The family's physician should participate in this disposition planning; if not, the physician's agreement and consent to the disposition should be sought. While the child is in temporary placement, the physician 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. The physician's input is integral to the decision for reuniting the child and parents. As the dynamics of the family setting improve, the child may be able to return to the parents' care. However, recurrences of abuse are common.
Prevention
Prevention of maltreatment should be a part of every well-child office visit through education of parents or caregivers and referrals for appropriate community services of identified at-risk families. Parents who have been victims of abuse or neglect may be at risk of abusing their own children. Such 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 risk. 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 infant's health can weaken parent-infant bonding (see also Caring for Sick Children and Their Families: Sick Neonates). During such times it is important to elicit the parents' feelings about their own inadequacies 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 in such settings goes a long way toward preventing tragic events.
Last full review/revision December 2009 by Ann S. Botash, MD
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