In 2020, 3.9 million reports of alleged child maltreatment were made to Child Protective Services (CPS) in the US involving 7.1 million children. About 2.1 million of these reports were investigated in detail, and about 618,000 maltreated children were identified (1 General references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ). Maltreatment rates were higher among girls (8.9 per 1000 girls) than boys (7.9 per 1000 boys). The younger the child is, the higher the rate of victimization (about 29% were age 2 or younger) (1 General references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ).
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 2020, 76.1% involved neglect (including medical neglect), 16.5% involved physical abuse, 9.4% involved sexual abuse, and 0.2% involved sex trafficking (1 General references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ). Many children were victims of multiple types of maltreatment.
About 1750 children died in the US of maltreatment in 2020, about half of whom were < 1 year old. About 73% of these children were victims of neglect and 43% were victims of physical abuse with or without other forms of maltreatment. About 80% of perpetrators were parents acting alone or with other individuals (1 General references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ).
Potential perpetrators of child maltreatment are defined slightly differently in different US states, but, in general, to legally be considered abuse, actions must be done by a person responsible for the child's welfare. Thus, parents and other relatives, people living in the child's home who have occasional responsibility, teachers, bus drivers, counselors, and so forth may be perpetrators. People who commit violence against children who they have no connection to or responsibility for (eg, as in school shootings) are guilty of assault, murder, and so forth but legally are not committing child abuse.
In addition to immediate harm, neglect and abuse increase the risk of long-lasting problems, including mental health problems and substance use disorders. Child abuse is also associated with problems in adulthood such as obesity Obesity Obesity is a chronic, multifactorial, relapsing disorder characterized by excess body weight and defined as a body mass index (BMI) of ≥ 30 kg/m2. Complications include cardiovascular disorders... read more , heart disease, and chronic obstructive pulmonary disease Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more (COPD) (2 General references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ).
1. US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau: Child Maltreatment 2020 (2022). Available at the Children's Bureau web site.
2. Waehrer GM, Miller TR, Silverio Marques SC, et al: Disease burden of adverse childhood experiences across 14 states. PLoS One 15(1):e0226134, 2020. doi: 10.1371/journal.pone.0226134
Classification of Child Maltreatment
Different forms of maltreatment often coexist, and overlap is considerable. The 4 main forms include
In addition, intentionally feigning, falsifying, or exaggerating medical symptoms in a child that results in potentially harmful medical interventions is considered a form of abuse (child abuse in a medical setting).
Physical abuse involves a caregiver inflicting physical harm or engaging in actions that create a high risk of harm. Assault by someone who is not a caregiver or in a position of responsibility to the child (eg, a shooter in a school mass shooting) is not specifically child abuse. Specific forms include shaking, dropping, striking, biting, and burning (eg, by scalding or touching with cigarettes).
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. Abuse is the most common cause of serious head injury in infants. In toddlers, abdominal injury is also common. Children in these age groups are also at increased risk of brain and spine injuries because of the relative size of their head to their body and because they have weaker neck muscles.
The risk of physical abuse declines in the early school years.
Any action with a child that is done for the sexual gratification of an adult or significantly older (developmentally or chronologically) child constitutes sexual abuse ( see Pedophilic Disorder Pedophilic Disorder Pedophilic disorder is characterized by recurrent, intense sexually arousing fantasies, urges, or behaviors involving sexual activity with prepubescent children (generally ≤ 13 years); based... read more ). The guidelines that differentiate sexual abuse from play vary from state to state, but in general sexual contact between individuals with a > 4-year (chronologically, or in mental or physical development) age difference is considered to be inappropriate.
Forms of sexual abuse include
Intercourse, which is oral, anal, or vaginal penetration
Molestation, which is genital contact without intercourse
Forms that do not involve physical contact by the perpetrator, including exposure of the perpetrator's genitals, showing sexually explicit material to a child, sexting with or posting pictures of a child, and forcing a child to participate in a sex act with another person or to participate in the production of sexual material
Sexual abuse does not include sexual play, in which children close in age and development view or touch each other’s genital area without force or coercion.
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
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 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.
Different types of neglect can be defined as
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 care or needed treatment for injuries or physical or mental disorders.
However, failure to provide preventive care (eg, vaccinations, routine dental examinations) is not usually considered neglect.
Child abuse in a medical setting
Child abuse in a medical setting (previously called Munchausen syndrome by proxy, now called factitious disorder imposed on another Factitious Disorder Imposed on Self Factitious disorder is falsification of physical or psychologic symptoms without an obvious external incentive; the motivation for this behavior is to assume the sick role. Symptoms can be acute... read more in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) 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.
Victims of this type of child abuse receive unnecessary and harmful or potentially harmful evaluations, tests, and/or treatments, including procedures or surgeries.
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, practices that are accepted by some cultures constitute abuse in the US (eg, female genital mutilation Female Genital Mutilation Female genital mutilation is a traditional practice in some cultures in parts of Africa (usually northern or central Africa). It is also done in some parts of the Middle East and in other areas... read more ). However, certain folk remedies (eg, coining, cupping Cupping Cupping (a manipulative and body-based practice) is used in traditional Chinese medicine. Cupping is believed to increase blood flow to the site of application, thereby improving healing in... read more , irritant poultices) may create lesions (eg, bruises, petechiae, minor burns) that can raise concern for what is acceptable cultural practices or abuse.
Members of certain religious 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’ beliefs. Additionally, in the US, some caregivers refuse to have their children vaccinated, citing safety concerns ( see Vaccine Hesitancy Vaccine Hesitancy Despite the rigorous vaccine safety systems in place in the United States, some parents remain concerned about the safety of the use and schedule of vaccines in children. These concerns have... read more ). It is not clear whether this refusal of vaccination is true medical neglect. However, in the face of illness, refusal of medically accepted treatment sometimes requires further investigation and legal intervention.
Etiology of Child Maltreatment
Generally, abuse can be attributed to a breakdown of impulse control in the parent or caregiver. Several factors can 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 many cases, also included 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. Substance use may provoke impulsive and uncontrolled behaviors toward children. Untreated parental mental health disorders also increase the risk of maltreatment.
A parent may reach their threshold for frustration and subsequent abusive actions more easily and frequently with children with special needs and/or difficult behaviors (1 Etiology reference Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ). 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.
All types of abuse, including sexual abuse, occur across the spectrum of socioeconomic groups. Socioeconomic stress (eg, financial stress, social isolation, young or single parenthood) is associated with increased risk. Physical abuse, emotional abuse, and neglect may be associated with poverty and lower socioeconomic status.
Neglect usually results from a combination of factors such as difficulties with parenting, poor stress-coping skills, unsupportive family systems, and stressful life circumstances. Neglect often occurs in families experiencing financial and environmental stresses, particularly those in which parents also have untreated mental health disorders (typically depression, anxiety, bipolar disorder, or schizophrenia), have a substance use disorder, 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 of Child Maltreatment
Symptoms and signs depend on the nature and duration of the abuse or neglect.
Skin lesions are the most common findings. Skin findings are usually subtle (eg, a small bruise, petechiae on the face and/or neck) (1 Symptoms and signs reference Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ).
More severe findings 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
Thickened skin or scarring at the corners of the mouth caused by being gagged
Patchy alopecia, with varying hair lengths, caused by hair pulling
Fractures highly indicative of physical abuse include classic metaphyseal lesions (usually caused by shaking an infant or toddler), rib fractures, and spinous processes fractures. Fractures most frequently associated with physical abuse include skull fractures, long bone fractures, and rib fractures. In children < 1 year old, about 75% of fractures are inflicted by others.
Confusion and localizing neurologic abnormalities can occur with central nervous system 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.
Older children who are frequently abused are often fearful and irritable and sleep poorly. They may have symptoms of depression Depressive Disorders in Children and Adolescents Depressive disorders are characterized by sadness or irritability that is severe or persistent enough to interfere with functioning or cause considerable distress. Diagnosis is by clinical criteria... read more , posttraumatic stress Acute and Posttraumatic Stress Disorders (ASD and PTSD) in Children and Adolescents Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are reactions to traumatic events. The reactions involve intrusive thoughts or dreams, avoidance of reminders of the event... read more reactions, or anxiety Overview of Anxiety Disorders in Children and Adolescents Anxiety disorders are characterized by fear, worry, or dread that greatly impairs the ability to function normally and that is disproportionate to the circumstances at hand. Anxiety may result... read more . Sometimes victims of abuse display symptoms similar to those of attention-deficit/hyperactivity disorder Attention-Deficit/Hyperactivity Disorder (ADD, ADHD) Attention-deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity, and impulsivity. The 3 types of ADHD are predominantly inattentive, predominantly hyperactive/impulsive... read more (ADHD) and are mistakenly diagnosed with that disorder. Violent or suicidal behavior may occur.
Pearls & Pitfalls
In most cases, children do not spontaneously disclose sexual abuse and do not always 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 walking or sitting
Bruises or tears around the genitals, anus, or mouth
Vaginal discharge, bleeding, or pruritus
Other manifestations include a sexually transmitted infection or pregnancy. Within a few days of the abuse, examination of the genitals, anus, and mouth will likely be normal, but the examiner may find healed lesions or subtle changes.
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 may be a sign of 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 apparent 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 develop a substance use disorder.
Undernutrition, fatigue, poor hygiene, lack of appropriate clothing, and failure to thrive Failure to Thrive (FTT) in Children Failure to thrive in children is weight consistently below the 3rd to 5th percentile for age and sex, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in 2 major... read more 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.
Symptoms and signs reference
1. Pierce MC, Kaczor K, Douglas JL, et al: Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open 4(4):e215832, 2021. doi: 10.1001/jamanetworkopen.2021.5832
Diagnosis of Child Maltreatment
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
Evaluation of injuries and nutritional deficiencies Overview of Undernutrition Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more 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 an at least median-level income. However, 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 (if they are developmentally able to provide it) and their nonoffending 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.
(See also evaluation guidelines for suspected child 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 the history of a significant injury
History that is inconsistent with the injury (eg, bruises on the backs of the legs attributed to a forward fall) or apparent stage of resolution (eg, old injuries described as recent)
History that varies depending on the information source or over time (it must be acknowledged that some discrepancies may be attributed to how the information was documented by the clinician)
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
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 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 allegedly 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 or at least cruising (ie, walking with support of objects in the environment) has a serious injury. Young infants with seemingly minor injuries should also 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 Physical abuse 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 year old with suspected abuse. Retinal hemorrhages occur in 85 to 90% of cases of abusive head trauma vs < 10% of cases of accidental head trauma. However, retinal hemorrhages are not pathognomonic of abuse (1 Diagnosis references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ). They also may result from childbirth and persist for 4 or more weeks. 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 months old (previous recommendation 24 months) 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 rarely done on children > 3 years old. 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 Osteogenesis Imperfecta Osteogenesis imperfecta is a hereditary collagen disorder causing diffuse abnormal fragility of bone and is sometimes accompanied by sensorineural hearing loss, blue sclerae, dentinogenesis... read more , rickets, and congenital syphilis Congenital Syphilis Congenital syphilis is a multisystem infection caused by Treponema pallidum and transmitted to the fetus via the placenta. Early signs are characteristic skin lesions, lymphadenopathy... read more . In inherited copper deficiency Inherited Copper Deficiency (Menkes Syndrome) Copper is a component of many body proteins; almost all of the body’s copper is bound to copper proteins. Copper deficiency may be acquired or inherited. (See also Overview of Mineral Deficiency... read more (Menkes syndrome), osteoporosis may lead to bone fractures.
Sexually transmitted infections Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more (2 Diagnosis references Child maltreatment includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (eg, clergy, coach, teacher) that results... read more ) in a child < 12 years old are nearly always the result 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 should be examined for evidence of injury. If the suspected abuse is thought to have occurred recently (≤ 96 hours), forensic evidence should be gathered using an appropriate kit and handled according to required legal standards ( see Testing and evidence collection Testing and evidence collection Sexual assault is any type of sexual activity or contact that a person does not consent to. Sexual assault, including rape, may cause physical injury or illness or psychologic trauma. Survivors... read more ). 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.
1. Maguire SA, Watts PO, Shaw AD, et al: Retinal haemorrhages and related findings in abusive and non-abusive head trauma: A systematic review. Eye (Lond) 27(1):28–36, 2013. doi: 10.1038/eye.2012.213
2. Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect; American Academy of Pediatrics: The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics 132(2):e558–e567, 2013. doi: 10.1542/peds.2013-1741
Treatment of Child Maltreatment
Treatment of injuries
Reporting to the appropriate agency
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.
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 US states to report incidents of suspected abuse or neglect (see Mandatory Reporters of Child Abuse and 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 caregivers that a report is being made pursuant to the law and that they will be contacted, interviewed, and likely visited at their home if the report is accepted. 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 conduct an evaluation of the events and the child's circumstances and can help the physician or other professional determine likelihood of subsequent harm and thus identify the best immediate disposition for the child. Options include
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
A malnourished child suspected to be a victim of neglect should be hospitalized and given nutrition in an age-appropriate fashion before any other supportive nutritional care is initiated (eg, gastrostomy tube). A child who begins to thrive while hospitalized is potent evidence of neglect (or poverty with lack of food).
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 layperson's terms) and an opinion as to the likelihood that the child was maltreated.
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 young children have a disability or delayed development, they may request an evaluation from their state's Early Intervention system (see Early Intervention Services), 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 US state to US 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 of Child Maltreatment
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 sometimes 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 years of age are also at increased risk of abusing their children.
Often, maternal risk factors for abuse are identified prenatally (eg, a mother who smokes, has a substance use disorder, has a history of domestic violence). Medical problems during pregnancy, delivery, or early infancy that may affect the health of the mother and/or the infant can weaken parent-infant bonding ( see also Caring for Sick Neonates Caring for Sick Neonates Difficulties arise when a sick or premature infant must be taken away from the family after birth because of illness. The parents may not be able to see a critically ill infant during stabilization... read more ). 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.
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Mandatory Reporters of Child Abuse and Neglect: Information about who is required to report abuse by state in the US
Early Intervention Services: Services by US state for infants and toddlers
Child Welfare Information Gateway: Child welfare information gateway from the US government containing guidance on many aspects of child abuse as well as listings of state and federal resources
Child Welfare Information Gateway: Child Abuse and Neglect: Specific information on child abuse, including definitions, identification, risk factors, mandatory reporting, and much else
Prevent Child Abuse America: Children's charity focusing on child abuse with much useful information for parents and health care practitioners and information about public policy
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