Child abuse

Child abuse is behavior toward a child that is outside of generally accepted norms and poses a significant risk of causing physical or emotional harm to the child. There are generally four types of abuse: physical abuse, sexual abuse, emotional abuse (psychological abuse), and neglect. The causes of child abuse vary and are not fully understood. Child abuse and neglect often result in physical injury, delayed growth and development, and mental health problems. Diagnosis is based on the medical history and physical examination. Clinical management includes identifying, documenting, and treating any injuries and physical or mental health emergencies, mandatory reporting to appropriate government agencies, and sometimes hospitalization or other measures to ensure the child is safe, such as foster care.

In 2002, 1.8 million cases of child abuse or neglect were reported in the United States, and 896,000 cases were substantiated. Children of both sexes were affected at equal rates.

In 2002, approximately 1,400 children died in the United States as a result of abuse, approximately three-quarters of whom were under age 4. One-third of the deaths were due to neglect. Children from birth to age 3 are the most frequently abused children (16/1,000 children). More than one-half of all reports to Child Protective Services were made by professionals charged with identifying and reporting child abuse (e.g., teachers, social workers, law enforcement, child care providers, medical and mental health workers, and child welfare workers).

Of the confirmed cases of child abuse in the United States in 2002, 60.2% involved neglect (including medical); 18.6% involved physical abuse; 9.9% involved sexual abuse; and 6.5% involved emotional abuse. In addition, 18.9% of children experienced other types of abuse, such as abandonment and substance abuse. Many children suffered from multiple types of abuse simultaneously. In more than 80% of confirmed cases of child abuse or neglect, the abuse was by a parent; in 58% of cases, it was by a woman.

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Classification of Child Abuse

Various forms often coexist, overlapping to a considerable extent.

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Physical abuse of children

Physical abuse is causing physical harm to a child or encouraging behavior that poses a high risk of harm. A child may be shaken, dropped, hit, bitten, or burned (for example, with boiling water or a cigarette). Severe corporal punishment is included in physical abuse, but may be determined by community factors. Abuse is the most common cause of severe head injuries in young children. Abdominal injuries are common in young children.

Children in the first years of life are most vulnerable (probably because they cannot complain), then the frequency decreases in the primary school age, and then increases again in adolescence.

Child sexual abuse

Any act with a child that is intended for the sexual gratification of an adult or significantly older child is sexual abuse. Forms of sexual abuse include sexual intercourse, i.e. oral, anal, or vaginal penetration; molestation, i.e. genital contact without penetration; and non-specific forms that do not involve physical contact, including exposing a child to sexual materials, forcing a child to participate in sexual intercourse with another child, or participating in the filming of pornographic materials.

Sexual abuse does not include sexual play, where children of similar ages (most often under 4 years of age each) look at or touch each other's external genitalia without coercion.

Emotional abuse of children

Emotional abuse is the infliction of emotional harm through words or actions. Parents may scold children by yelling and screaming, treat the child with contempt, belittle the child's abilities and achievements, intimidate and terrorize the child by threats, exploit the child, or encourage defiant or criminal behavior. Emotional abuse may also occur when words or actions are ignored or interrupted, essentially emotional neglect (for example, ignoring or abandoning the child, or isolating the child from other children or adults).

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Child neglect

Neglect is the failure to provide for a child's basic physical, emotional, educational, and health needs. Neglect differs from abuse in that it usually occurs without the intent to harm the child. Physical neglect involves failing to provide a child with adequate food, clothing, shelter, supervision, and protection from potential harm. Emotional neglect involves failing to provide a child with affection, love, or other emotional support. Educational neglect involves failing to enroll a child in school, supervising school attendance, or completing homework. Medical neglect involves failing to ensure that a child receives appropriate preventive care, such as vaccinations, or receives necessary treatment for injuries or physical or mental illness.

Causes of Child Abuse

Violence. In general, violence can be a manifestation of loss of control by parents or other persons caring for the child. Several important factors are identified.

Parental characteristics and personality traits may play a role. The parents themselves may have received little affection and warmth as children, were in an environment that was not conducive to adequate self-esteem or emotional maturation, and in most cases experienced some form of abuse themselves. Such parents may view their children as an unlimited and unconditional source of love and support that they never received. As a result, they may develop inappropriate expectations of what their child can give them; they are easily disappointed and lose control; they may be unable to give their child what they themselves have never experienced. Drugs or alcohol may trigger impulsive and uncontrollable behavior toward the child. Mental disorders in parents may increase the risk; in some cases, child abuse occurs while the parent is psychotic.

Restless, demanding or hyperactive children, as well as children with disabilities due to physical or mental disorders, who are always more dependent, can provoke outbursts of irritation and anger in parents. Sometimes a strong emotional attachment does not develop between parents and a premature or sick child, isolated from parents in the first days of life, as well as with biologically unrelated children (for example, children of spouses from a previous marriage), which increases the likelihood of domestic violence.

Stressful situations can increase the likelihood of child abuse, especially if emotional support from family, friends, neighbors, or peers is not available.

Physical abuse, emotional abuse, and neglect are often associated with poverty and low socioeconomic status. However, all types of abuse, including sexual abuse, occur across all socioeconomic groups. The risk of sexual abuse is increased for children who are cared for by multiple people or who are cared for by a person who has multiple sexual partners.

Neglect. Neglect is often seen in poor families, where parents also have mental disorders (usually depression or schizophrenia), drug or alcohol addiction, or low intelligence. The departure of a father who is unable or unwilling to take responsibility for the family can trigger and exacerbate neglect. Children of mothers who use cocaine are especially at risk of child abandonment.

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Symptoms of Child Abuse

Symptoms and signs depend on the nature and duration of child abuse.

Physical abuse. Skin lesions are common and may include palm prints or oval fingerprints from slapping, roughly grasping, and shaking; long, ribbon-like ecchymoses from belt blows or narrow, arcuate bruises from blows with a taut rope or cord; multiple small, circular cigarette burns; symmetrical burns to the extremities or buttocks from deliberate immersion in hot water; bite marks; thickened skin or welts at the corners of the mouth from gagging. Alopecia areata may result from hair pulling.

Fractures commonly associated with physical abuse include rib, spinal, long-bone, and finger fractures in children who cannot walk independently, as well as metaphyseal fractures. Confusion and focal neurologic signs may develop with CNS injury. Infants who have been roughly and vigorously shaken may be comatose or stuporous due to brain injury, although there may be no outward signs of injury (retinal hemorrhages are a common exception). Traumatic injury to internal organs in the chest or abdomen may also occur without any outward signs.

Children who are frequently abused tend to be fearful and restless, and have poor sleep. They may appear depressed or anxious.

Sexual abuse. Most children do not freely report sexual abuse or show behavioral or physical signs of it. In some cases, sudden or extreme changes in behavior may occur. Aggression or withdrawal may develop, as may phobias or sleep disturbances. Some children who are sexually abused exhibit age-inappropriate sexual behavior. Physical signs of sexual abuse may include difficulty walking or sitting; bruises, abrasions, or tears around the genitals, rectum, or mouth; vaginal discharge or itching; or sexually transmitted diseases. If a child does disclose sexual abuse, it is usually late, sometimes days or even years later. After a period of time (from a few days to 2 weeks), the genitals may return to normal or there may be healed, subtle changes in the hymen.

Emotional Abuse. During the first months of life, emotional abuse can dull emotional expression and reduce interest in the environment. Emotional abuse often results in malnutrition and is often misdiagnosed as mental retardation or physical illness. Delayed development of social and verbal skills is often a consequence of inadequate stimulation and interaction with parents. Children who are emotionally abused may be insecure, anxious, distrustful, superficial in interpersonal relationships, passive, and overly concerned with pleasing adults. Children who are despised and ridiculed by their parents often have low self-esteem. Children who are bullied by their parents may appear fearful and withdrawn. The emotional impact on children usually becomes apparent during school age, when difficulties in forming relationships with peers and teachers develop. Often, the emotional effects can only be appreciated after the child is placed in a different environment or the parents' behavior changes to be more appropriate. Children who are forced to act in their own interests may commit crimes or use drugs or alcohol.

Neglect. Poor nutrition, weakness, lack of hygiene or proper clothing, and undernutrition are common signs due to inadequate food, clothing, or shelter. Stunting and death from starvation or abandonment may occur.

How to recognize child abuse?

Evaluation of trauma and malnutrition are discussed elsewhere in this guide. Identifying child abuse as a cause can be difficult and requires maintaining a high index of suspicion. Acute head trauma inflicted by either parent is often underdiagnosed in intact, middle-income families.

Sometimes direct questions can provide answers. Children who have been abused may be able to describe the events and the person who perpetrated them, but some children, especially those who have been sexually abused, may be under pressure to keep secrets, may be so frightened or traumatized that they are extremely reluctant to talk (and may even deny the abuse if specifically asked). The child should be interviewed alone, calmly asking open-ended questions; yes-or-no questions (Did your dad do this?, Did he touch you here?) can easily paint a distorted picture of events in young children.

The examination includes observation of the interaction between the child being abused and those possibly responsible, whenever possible. All examination findings and history should be recorded as fully and accurately as possible, including recording direct quotes from the story and photographs of injuries.

Physical Abuse. Both the history and physical examination provide clues that a child may have been abused. Signs that suggest child abuse include parental unwillingness or inability to explain the origin of the child's injuries; a history that is inconsistent with the nature of the injuries (e.g., bruises on the back of the legs that parents attribute to a fall) or that is clearly in the process of resolving (i.e., old injuries that parents interpret as recent); a history that varies depending on the source of the information; a history of injury that is inconsistent with the child's developmental stage (e.g., injuries attributed to a fall down stairs in a child too young to crawl); parental inappropriate response to the severity of the injury, either being overly concerned or careless; and delayed seeking help.

The main signs of abuse on examination are atypical injuries and injuries that are inconsistent with the history given by the parents. Injuries in children resulting from falls are usually solitary and located on the forehead, chin, or mouth area or on the extensor surfaces of the extremities, especially the elbows, knees, forearms, and shins. Bruises on the back, buttocks, and back of the legs are extremely rare consequences of falls. Fractures, with the exception of a fracture of the clavicle and a fracture of the radius in a typical location (Colles' fracture), are less common in ordinary falls during play or from stairs. There are no fractures that are pathognomonic of physical abuse, but classic metaphyseal injuries, rib fractures (especially posterior and 1st ribs), depressed or multiple skull fractures with apparently minor trauma, fractures of the scapula, fractures of the sternum and spinous process should raise suspicion.

Physical abuse should be suspected when a significant injury is found in a child who is not yet walking. Infants in the first months of life with minor facial injuries should be further evaluated. Infants in the first months of life may appear perfectly healthy or asleep despite significant brain injury; any infant who is lethargic, apathetic, or sleepy should have acute head injury due to child abuse as part of the differential diagnosis. Also suspicious is the presence of multiple injuries in various stages of healing; skin changes characteristic of certain types of injuries; and repeated injuries that suggest abuse or inadequate supervision.

Retinal hemorrhages are observed in 65-95% of children who were roughly shaken, they are extremely rare in accidental head trauma. Also, retinal hemorrhages can be present from birth and persist for 4 weeks.

Children younger than 2 years who have been physically abused should have a skeletal examination to look for evidence of previous bone injuries [fractures in various stages of healing or subperiosteal growths (protrusions) of long bones]. The examination is also sometimes performed in children aged 2 to 5 years; in children older than 5 years, the examination is usually ineffective. Standard examination includes radiographs of the skull and chest in the AP projection, the spine and long bones in the lateral projection, the pelvis in the AP projection, and the hands in the AP and oblique projections. Diseases in which multiple fractures may be observed include osteogenesis imperfecta and congenital syphilis.

Sexual abuse. Any sexually transmitted disease (STI) in a child under 12 years of age should be assumed to be a consequence of sexual abuse until proven otherwise. If a child has been sexually abused, the only initial indication that the incident has occurred may be a change in behavior (e.g., restlessness, fearfulness, insomnia). If sexual abuse is suspected, the perioral and perianal areas and the external genitalia should be examined for signs of injury. If the episode is suspected to be recent, hair samples and smears of body fluids should be taken for legal evidence. A light source with magnification and a camera to record the injuries (e.g., a specially equipped colposcope) may be used to obtain legal evidence.

Emotional Abuse and Neglect: The evaluation focuses on the child’s overall appearance and behavior to determine whether the child is developing abnormally. Teachers and social workers are often the first to identify neglect. A physician may notice that a child is not showing up for appointments or immunizations that were not recently scheduled. Medical neglect in children with severe, life-threatening chronic illnesses, such as reactive airway dysfunction syndrome or diabetes, may lead to subsequent increased physician visits, emergency room admissions, and noncompliance with the child’s treatment.

Treatment for Child Abuse

Treatment is primarily aimed at addressing immediate health issues (including possible STDs) and ensuring the safety of the child. Ultimately, treatment is aimed at normalizing long-term disrupted interpersonal interactions. Both abuse and neglect require a supportive rather than punitive approach to the family.

Immediate safety of the child. Physicians and other professionals who work with children (e.g., nurses, teachers, child care personnel, police) are required by law in all states to report abuse or suspected abuse. Laws vary by state. The general public is also encouraged to report child abuse, but is not required to do so. Any person who reports abuse and provides a reasonable and truthful explanation is protected from criminal and civil liability. A professional who is required by law to report abuse and who fails to do so may be subject to criminal or civil penalties. Abuse is reported to Child Protective Services or other appropriate agencies. Health care providers may, but are not required to, notify parents that they are legally reporting their suspicions to the appropriate authorities and that the parents will be contacted, interviewed, and possibly visited at home. In some cases, the physician may determine that informing the parents before police or other services are available may pose a high risk of injury to the child. In these circumstances, informing the parents or caregivers may be delayed.

Child protection representatives and social workers can help the doctor determine the likelihood of further harm to the child and thus determine where the child would be best placed. Options include protective hospitalization, placement with relatives or temporary housing (sometimes the entire family moves out of the home of the partner who is terrorizing them), temporary placement with a foster family, and returning the child to the home with adequate supervision by social services. The doctor plays a vital role in working with community agencies to argue and advocate for the best and safest placement for the child.

Observation. The primary care source is the foundation. However, families of abused children often move, making continuous observation of the child difficult. Often parents do not keep appointments; home visits by social workers or community representatives or nurses may be necessary to ensure that all appointments are successfully completed.

A thorough examination of the family background, previous contacts with social services, and the needs of the parents is essential. A social worker can conduct this examination and assist with interviews and work with family members. The social worker also provides tangible assistance to parents in obtaining public assistance and enrolling the child in a child care facility, as well as assistance with household chores (which can relieve parents of stress by giving them a few hours a day to relax), and coordinates psychological and psychiatric care for parents. Periodic or ongoing contacts with social services are usually necessary.

In some places, parenting programs are available that employ trained professionals to work with abusive parents. Other types of parenting support, such as support groups, are also effective.

Sexual abuse can have long-lasting effects on a child's development and sexual adjustment, especially among older children and adolescents. Counseling or psychotherapy for the child and the adults involved can reduce these effects.

Removing a Child from the Home. Although temporary removal of a child from the home until a full investigation has been completed and the child's safety has been ensured is not uncommon, the ultimate goal of Child Protective Services is to keep the child with his or her family in a safe, healthy environment. If the above measures do not achieve this, permanent removal of the child from the home and possibly termination of parental rights should be considered. This serious step requires a court order presented by the appropriate officials. The procedure for termination of parental rights varies from state to state but usually involves a physician testifying in court. If the court decides to remove the child, it must determine where the child will live. The family physician should be involved in determining the child's placement; if not, his or her consent should be obtained. While the child is being temporarily removed from the home, the physician should maintain contact with the parents whenever possible to ensure that proper attempts are being made to help them. Sometimes children are abused while in foster care. The doctor must be prepared for such events. The doctor's opinion plays a significant role in deciding the issue of family reunification. With the improvement of conditions in the family, the child can return to the parents. At the same time, repeated episodes of violence in the family are common.

How to prevent child abuse?

Prevention of child abuse should be addressed at every health care visit by providing information to parents or caregivers and by contacting appropriate services when families at increased risk of child abuse are identified. Parents who were abused or neglected as children are more likely to abuse their children later in life. Such parents often express concern about their own tendency to abuse in the family and are highly treatable. Parents are also at high risk of child abuse when raising their first child, when the parents are teenagers, or when there are several children under 5 years of age in the family. Often, risk factors for the mother can be identified before the baby is born, such as failure to follow doctor’s orders, failure to keep appointments, smoking, using drugs, or having a history of domestic violence. Medical problems during pregnancy, childbirth, and the early neonatal period that may affect the health of the baby may weaken the attachment between parent and child. During these times, it is important to explore the parents’ feelings about their own inadequacy and the well-being of the baby. How well can they relate to a child with many needs or health problems? Do the parents provide each other with emotional and physical support? Are there relatives or friends who can help if needed? A doctor who is alert to these key issues and can provide support in these circumstances goes a long way toward preventing tragic events.