Child Abuse and Neglect


Article Author:
Dulce Gonzalez


Article Editor:
Janelle McCall


Editors In Chief:
Rudolf Bickel
Abdolreza Saadabadi
Cornel Stanciu


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/15/2018 11:28:36 PM

Introduction

The World Health Organization (WHO) defines child maltreatment as “all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity.” There are four main types of abuse: neglect, physical abuse, psychological abuse and sexual abuse. Abuse is defined as an act of commission and neglect is defined as an act of omission in the care leading to potential or actual harm.

  • Neglect may include inadequate health care, education, supervision, protection from hazards in the environment, and unmet basic needs such as clothing and food. Neglect is the most common form of child abuse.
  • Physical abuse may include beating, shaking, burning, and biting. The threshold for defining corporal punishment as abuse is unclear. Rib fractures are found to be the most common finding associated with physical abuse.
  • Psychological abuse includes verbal abuse, humiliation, and acts that scare or terrorize a child, which may result in future psychological illness of the child.
  • Sexual abuse is defined as “the involvement of dependent, developmentally immature children and adolescents in sexual activities which they do not fully comprehend, to which they are unable to give consent, or that violate the social taboos of family roles.” Some cases of sexual abuse do not need to involve oral, anal, or vaginal penetration and may include exposure to sexually explicit materials, oral-genital contact, genital-to-genital contact, genital-to-anal contact, and genital fondling.

A significant amount of child abuse cases frequently are missed by healthcare providers. For the diagnosis of child abuse to be made, there needs to be a high index of suspicion.[1][2][3]

Etiology

All races, ethnicities, and socioeconomic groups are affected by child abuse with boys and adolescents more commonly affected. Infants tend to have increased morbidity and mortality with physical abuse. Multiple factors increase a child’s risk for abuse. These include risks at an individual level (child’s disability, unmarried mother, maternal smoking or parent’s depression); risks at a familial level (domestic violence at home, more than two siblings at home); risks at a community level (lack of recreational facilities); and societal factors (poverty). Other risk factors include living in an unrelated adult’s home and being a child previously reported to child protective services (CPS). All of these increase the risk for child maltreatment. There are also protective factors that decrease the risk for child maltreatment, which includes family support and parental concern. Preventive factors include parental education regarding child development and parenting, social support, as well as parental resilience.[4][5][6]

Epidemiology

Each year, millions of children are investigated by the Child Protective Services for child abuse and neglect. In 2014, over 3.2 million children were subjects of child maltreatment reports, of those, 20% were found to have evidence of maltreatment.[7]

History and Physical

To diagnose a patient with child maltreatment is difficult since the victim may be nonverbal or too frightened or severely injured to talk. Also, the perpetrator will rarely admit to the injury, and witnesses are uncommon. Physicians will see children of maltreatment in a range of ways that include:

  • An adult or mandated reporter may bring the child in when they are concerned for abuse
  • A child or adolescent may come in disclosing the abuse
  • The perpetrators may be concerned that the abuse is severe and bring in the patient for medical care
  • The child may present for care unrelated to the abuse, and the abuse may be found incidentally.

Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is important to make a correct diagnosis. Important aspects of the history-taking involve gathering information about the child’s behavior before, during, and after the injury occurred. History-taking should include the interview of each caretaker separately and the verbal child, as well. The parent or caretaker should be able to provide their history without interruptions in order not to be influenced by the physician’s questions or interpretations.

Physical Abuse

Child physical abuse should be considered in each of the following:

  • A non-ambulatory infant with any injury
  • Injury in a nonverbal child
  • Injury inconsistent with child’s physical abilities and a statement of harm from the verbal child
  • Mechanism of injury not plausible; multiple injuries, particularly at varying ages
  • Bruises on the torso, ear or neck in a child younger than 4 years of age
  • Burns to genitalia
  • Stocking or glove distributions or patterns
  • Caregiver is unconcerned about injury
  • An unexplained delay in seeking care or inconsistencies or discrepancies in the histories provided. 

"TEN 4" is a useful mnemonic device used to recall which bruising locations are of concern in cases involving physical abuse: Torso, Ear, Neck and 4 (less than four years of age or any bruising in a child less than four months of age). A few injuries that are highly suggestive of abuse include retinal hemorrhages, posterior rib fractures, and classic metaphyseal lesions.

Bruising is the most common sign of physical abuse but is missed as a sentinel injury in ambulatory children. Bruising in non-ambulatory children is rare and should raise suspicion for abuse. The most common areas of bruising in non-abused children are the knees and shins as well as bony prominences including the forehead. The most common area of bruising for the abused children includes the head and face. Burns are a common form of a childhood injury that is usually not associated with abuse. Immersion burns have characteristic sharp lines of demarcation that often involves the genitals and lower extremities in a symmetric pattern, and this is highly suspicious for abuse.

Abusive Head Trauma

Abusive head trauma (AHT), also known as the shaken baby syndrome, is a form of child physical abuse with the highest mortality rate (greater than 20%). Symptoms may be as subtle as vomiting, or as severe as lethargy, seizures, apnea, or coma. Findings suggestive of AHT are retinal hemorrhages, subdural hematomas, and diffuse axonal injury. An infant with abusive head trauma may have no neurologic symptoms and may be diagnosed instead with acute gastroenteritis, otitis media, GERD, colic and other non-related entities. Often, a head ultrasound is used as the initial evaluation in young infants. However, it not the test of choice in the emergency setting. In the assessment of AHT, the ophthalmologic examination should be performed, preferably by a pediatric ophthalmologist.

Skeletal Trauma

The second most common type of child abuse after neglect is physical abuse. Eighty percent of abusive fractures occur in non-ambulatory children, particularly in children younger than 18 months of age. The most important risk factor for abusive skeletal injury is age. There is no fracture pathognomonic for abuse, but there are some fractures that are more suggestive of abuse.  These include posterior or lateral rib fractures and “corner” or “bucket handle” fractures, which occur at the ends of long bones and which result from a twisting mechanism. Other highly suspicious fractures are sternal, spinal and scapular fractures.

Abdominal Trauma

Abdominal trauma is a significant cause of morbidity and mortality in abused children. It is the second most common cause of death from physical abuse, mostly seen in infants and toddlers. Many of these children will not display overt findings, and there may be no abdominal bruising on physical exam. Therefore, screening should include liver function tests, amylase, lipase, and testing for hematuria. Any positive result can indicate the need for imaging studies, particularly an abdominal CT scan.

Sexual Abuse

If a child demonstrates behavior such as undressing in front of others, touching others' genitals, as well as trying to look at others underdressing, there may be a concern for sexual abuse. It is important to understand that a normal physical examination does not rule out sexual abuse. Indeed, the majority of sexual abuse victims have a normal anogenital examination. In most cases, the strongest evidence that sexual abuse has occurred is the child’s statement.

Neglect

Physical examination may not only demonstrate signs of physical abuse but may show signs of neglect. The general examination may show poor oral hygiene with extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds.

All healthcare providers are mandated reporters, and, as such, they are required to make a report to child welfare when there is a reasonable suspicion of abuse or neglect. One does not need to be certain, but one does need to have a reasonable suspicion of the abuse. This mandated report may be lifesaving for many children. An interdisciplinary approach with the inclusion of a child-abuse specialist is optimal.

Evaluation

Any child younger than two years old for whom there is a concern of physical abuse should have a skeletal survey. Additionally, any sibling younger than two years of age of an abused child should also have a skeletal survey. A skeletal survey consists of 21 dedicated views, as recommended by the American College of Radiology. The views include anteroposterior (AP) and lateral aspects of the skull; lateral spine; AP, right posterior oblique, left posterior oblique of chest/rib technique; AP pelvis; AP of each femur; AP of each leg; AP of each humerus; AP of each forearm; posterior and anterior views of each hand; AP (dorsoventral) of each foot. If the findings are abnormal or equivocal, a follow-up survey is indicated in 2 weeks to visualize healing patterns.

Laboratory evaluation may be performed to rule out other diseases as causes of the injuries. These can including bone (calcium, magnesium, phosphate, alkaline phosphatase), hematology (CBC), coagulation (PT, PTT, INR), metabolic (glucose, BUN, creatinine, albumin, protein), liver (AST, ALT), pancreatic (amylase and lipase), and bleeding diathesis (von Willebrand antigen, von Willebrand activity, Factor VIII, Factor IX and platelet function assays).

One should take into consideration that the most common differential diagnosis of non-accidental injury is an accidental injury.[8][9][10]

Treatment / Management

Initial management of an abused child involves stabilization, including assessing patient’s airway, breathing, and circulation. Once ensured that the patient is stable, a complete history and physical examination is required. With the suspicion for any form of child abuse, CPS needs to be informed. If there is a child abuse specialist at the pediatric center, their involvement would be optimal. If the patient is seen in an outpatient setting, there may be a need to transfer the patient to a hospital for laboratory and radiologic evaluation as well as the appropriate continuation of care. Even if a child was transferred to another physician or facility, the physician first involved with the patient care still has the responsibility of being a mandated reporter. It is not the responsibility of the physician to identify the perpetrator, but it is to recognize potential abuse. The physician can continue to advocate for the child, ensuring that the patient receives the appropriate follow-up services.

Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed as well as empiric treatment for HIV, gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection for the adolescent victims. This management is possible if the patients present within 72 hours of the incident to receive appropriate care as well as emergency contraception if desired. Prepubertal patients are not provided with the prophylactic treatment due to the low incidence of STIs in this age group. Urgent evaluation is beneficial in the patients who need prophylactic treatment, those with anogenital injury, for forensic evidence, optimally in less than 72 hours, for urgent child protection, and in those having suicidal ideation or any other form of symptom and/or injury requiring urgent medical care.[11][12][13]

Differential Diagnosis

  • Idiopathic thrombocytopenic purpura
  • Malignancy
  • Vascular malformations
  • Collagen vascular disorder 
  • Osteogenesis imperfecta
  • Hemophilia

Complications

  • Fractures
  • Burns
  • Disfigurement
  • Emotional trauma
  • Seizures
  • Mental retardation
  • PTSD

Consultations

  • Psychiatrist
  • Orthopedic surgeon  
  • Neurologist
  • Child protective services

 

 

 

Pearls and Other Issues

Child abuse is a public health problem that leads to lifelong health consequences, both physically and psychologically. Physically, those who undergo abusive head trauma may have neurologic deficits, developmental delays, cerebral palsy, and other forms of disability. Psychologically, child abuse patients tend to have higher rates of depression, conduct disorder, and substance abuse. Academically, these children may have poor performance at school with decreased cognitive function.

It is important as physicians to have a high index of suspicion for child maltreatment since early identification may be lifesaving.

Enhancing Healthcare Team Outcomes

When it comes to child abuse, all healthcare workers have a legal, medical and moral obligation to identify the problem and report it to CPS. The majority of child abuse problems present to the ER and nurses and physicians are often the first ones to notice the problem. The key is to be aware of the problem; allowing abused children to return back to their parents usually leads to more violence and sometimes even death. Even if child abuse is only suspected, the social worker must be informed so that the child can be followed as an outpatient. Despite the best practices, many children continue to suffer from child abuse.[14][15][16] (Level V)

Evidence-based outcomes

Child abuse is a serious problem in many countries. While there is an acute awareness of the problem, many children fail to be referred to CPS and consequently continue to suffer abuse, sometimes even death. In a busy emergency room, signs of child abuse are missed, and thus healthcare workers must be vigilant of abuse in any child who presents with injuries that are out of place. [2][17](Level V)


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Child Abuse and Neglect - Questions

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After taking a careful history and physical, what is the first step in a suspected child abuse?



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A child is attending therapy and is noted to have a bruise in the shape of an adult hand. What should the therapist do?



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Which of the following is least likely a causative factor for child neglect or abuse?



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Which occurrence at a healthcare facility requires mandatory notification to official agencies?



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When child abuse is suspected, which of the following statements is false?



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A 5-year-old male is brought to the emergency room with a fracture of the humerus. The mother reports that he fell off the bed. Bruising is also noted on examination in different stages of healing to the buttock area. How should this be documented?



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A 36-month-old with severe hearing loss is cared for by a grandfather during the day. The grandfather can be aggressive and suffers from alcohol use disorder. Which is true?



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A 4-month-old female is brought to the emergency department after she stopped breathing for about 30 seconds. The mother reports her lips turned blue and she didn't resume breathing until she blew in her face. The patient had no symptoms before the event. She is breastfed and has had all immunizations. On exam, the patient is alert and irritable. There is dried blood at both nares. Oxygen saturation is 97 percent on room air. The rest of the exam is normal. Electrolytes, serum glucose, and CT of the head are normal. Chest radiograph shows posterior rib fractures. Select the most likely diagnosis.

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A 21-month-old female is brought to the emergency department crying and pointing to her left arm. The mother denies recent fall, recent illness, fever, or any other complaint. Imaging of the left humerus demonstrates a lucency within the metaphysis. What is the most likely diagnosis in this patient?



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A 5-year-old male is brought in for a well child visit. On review of systems, the mother mentions patient is constantly touching his genital area. Mother also mentions the patient asks her to touch his genitalia. On physical exam vesicles are noted on the glans penis. What is the most likely diagnosis?



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A 5-year-old who lives with his mother and her boyfriend is seen because of recurrent anal fissures. He is otherwise healthy, and no medical cause has been identified despite an exhaustive workup. Which of the following may be a consideration?



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A mother presents her 2-year-old toddler with a first-degree burn of the left hand in a glove distribution. On examination, there are multiple healed 7 mm circular scars. What is the initial management?



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Which of the following listed injuries is uncommon to happen outside of abuse in an infant?



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Child Abuse and Neglect - References

References

Gershun M,Terrebonne C, Child welfare system interventions on behalf of children and families: Highlighting the role of court appointed special advocates. Current problems in pediatric and adolescent health care. 2018 Sep 14     [PubMed]
Liu Y,Merritt DH, Familial financial stress and child internalizing behaviors: The roles of caregivers' maltreating behaviors and social services. Child abuse     [PubMed]
Miller GF,Chiang L,Hollis N, Economics and violence against children, findings from the Violence Against Children Survey in Nigeria. Child abuse     [PubMed]
Zeanah CH,Humphreys KL, Child Abuse and Neglect. Journal of the American Academy of Child and Adolescent Psychiatry. 2018 Sep     [PubMed]
Wolford SN,Cooper AN,McWey LM, Maternal depression, maltreatment history, and child outcomes: The role of harsh parenting. The American journal of orthopsychiatry. 2018 Sep 10     [PubMed]
Hansen JB,Killough EF,Moffatt ME,Knapp JF, Retinal Hemorrhages: Abusive Head Trauma or Not? Pediatric emergency care. 2018 Sep     [PubMed]
Van Horne BS,Caughy MO,Canfield M,Case AP,Greeley CS,Morgan R,Mitchell LE, First-time maltreatment in children ages 2-10 with and without specific birth defects: A population-based study. Child abuse     [PubMed]
Christian CW,Levin AV, The Eye Examination in the Evaluation of Child Abuse. Pediatrics. 2018 Aug     [PubMed]
Vrolijk-Bosschaart TF,Brilleslijper-Kater SN,Benninga MA,Lindauer RJL,Teeuw AH, Clinical practice: recognizing child sexual abuse-what makes it so difficult? European journal of pediatrics. 2018 Jun 25     [PubMed]
Hu MH,Huang GS,Huang JL,Wu CT,Chao AS,Lo FS,Wu HP, Clinical characteristic and risk factors of recurrent sexual abuse and delayed reported sexual abuse in childhood. Medicine. 2018 Apr     [PubMed]
Tanoue K,Senda M,An B,Tasaki M,Taguchi M,Kobashi K,Oana S,Mizoguchi F,Shiraishi Y,Yamada F,Okuyama M,Ichikawa K, National survey of hospital child protection teams in Japan. Child abuse     [PubMed]
Girardet R,Bolton K,Hashmi S,Sedlock E,Khatri R,Lahoti N,Lukefahr J, Child protective services utilization of child abuse pediatricians: A mixed methods study. Child abuse     [PubMed]
Al Abduwani J,Sidebotham P,Al Saadoon M,Al Lawati M,Barlow J, The Child Abuse Potential Inventory: Development of an Arabic version. Child abuse     [PubMed]
Wood JN,Henry MK,Berger RP,Lindberg DM,Anderst JD,Song L,Localio R,Feudtner C, Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in Young Injured Children. Academic pediatrics. 2018 Aug 16     [PubMed]
Merrick MT,Guinn AS, Child Abuse and Neglect: Breaking the Intergenerational Link. American journal of public health. 2018 Sep     [PubMed]
Ringel JS,Schultz D,Mendelsohn J,Holliday SB,Sieck K,Edochie I,Davis L, Improving Child Welfare Outcomes: Balancing Investments in Prevention and Treatment. Rand health quarterly. 2018 Mar     [PubMed]
Rumball-Smith J,Fromkin J,Rsosenthal B,Shane D,Skrbin J,Bimber T,Berger RP, Implementation of routine electronic health record-based child abuse screening in General Emergency Departments. Child abuse     [PubMed]

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