What Should I Know about Child Abuse and Neglect?

After medical school, you will be mandated by law in all 50 states and in Canada to identify and report suspected child maltreatment and to work with child protection services to protect vulnerable children. Physicians in all areas of medical practice will encounter child abuse and family violence and must identify, report, and subsequently manage the families.

How Is Child Abuse Defined?

Abuse includes all behaviors that are destructive to the normal physical or emotional development of a child. Although laws vary somewhat, only parents and guardians may be reported for physical or emotional abuse and neglect, whereas any adult may be reported for sexual abuse. Medical professionals may have cultural or religious beliefs, family upbringing, or personal experiences that influence their own perceptions of abuse, but such differences must not prevent compliance with state-specific statutes that define abuse and codify the requirements for its identification and reporting.

How Common Is Child Maltreatment?

Each year, nearly 3 million reports of suspected maltreatment are made to child protection services in the United States, and approximately 1 million of these reports are confirmed. Thousands of childhood deaths each year are attributed to abuse, primarily in children younger than 3 years. These numbers represent only official reports. The true prevalence of child abuse is unknown, because many maltreated children are not brought to the attention of public agencies. Child protection agencies are overwhelmed with referrals and can only investigate approximately 60% of reports. Furthermore, after investigation, only 55% of child victims receive services.

Does Child Abuse Have Long-Term Effects for Adults?

Recent studies in California found that more than 10% of adults suffered physical and psychological abuse as children and more than 20% reported childhood sexual abuse. Childhood exposure to socially adverse experiences such as child abuse, living with addicted parents, domestic violence, and incarcerated parents was associated with higher rates of diseases and medical problems that predict adult morbidity and early mortality.

What Factors Are Associated with Child Abuse?

Child abuse results from the complex interaction of individual, familial, and societal risk factors (Table 24-1). These are broad markers of abuse and neglect, not strong individual determinants. You must have a high index of suspicion for abuse but must not rely solely on sociodemographic variables.

Table 24-1 Risk Factors Associated with Child Abuse

Is Poverty a Risk Factor for Abuse and Neglect?

Children from families with annual incomes less than $15,000 experience some form of abuse far more often than do children from families with annual incomes more than $30,000. In particular, poor children have high rates of educational neglect, serious physical injury, and sexual abuse. Substantiation rates for abuse and neglect rise as poverty level worsens.

Are Parental Mental Health Problems Associated with Abuse and Neglect?

Substance abuse and maternal depression are strongly associated with child maltreatment. Substance abuse rates are high among abusive parents, and rates of child maltreatment are high among substance abusers. Approximately 70% of families involved with the child protection system are affected by substance abuse. Depression is also a strong risk factor for physical abuse as it is highly prevalent in both the general population and among parents of abused children.

Does Abuse in Childhood Predispose a Parent to Abuse?

Intergenerational transmission of abuse is not inevitable. Although approximately one-third of adults who were abused in childhood later abuse or neglect their own children, the fact that an adult was abused does not in and of itself justify an investigation for possible child abuse. It is important, however, to assess an adult’s personal history of abuse when evaluating suspected child abuse.

Does Domestic Violence Increase Risk of Child Abuse?

The concurrence of child abuse and domestic violence approaches 50% in population-based studies. In families with severe domestic violence, the child abuse rates are even greater.

Do Child Factors Contribute to Maltreatment?

Children are never blamed for their maltreatment, but a number of child factors can be identified in cases of abuse.

How Are Abused Children Identified?

The diagnosis of child abuse requires a high level of suspicion based on a detailed history, a thorough physical examination, and careful interpretation of laboratory and radiographic tests. Obvious signs of battering are not always found. In most cases, discrepancies between the history of trauma and the resulting injuries suggest the diagnosis and trigger an evaluation.

What Clinical Clues Suggest Abuse?

The history provided by the adult accompanying the child is often inaccurate or deliberately falsified. Victims of abuse are often too young, too ill, or too scared to provide a history of their assault. Abused children may manifest behavioral problems, but no single behavior is pathognomonic for abuse. Ask about family violence and sexual abuse and look for unexplained or characteristic injuries. Table 24-2 lists clinical clues that suggest abuse.

Table 24-2 Clinical Clues or “Red Flags” That Suggest Child Abuse

Which Bruises Should I Worry About?

Bruises are universal in healthy ambulatory children, but they are also the most common injuries identified in abused children. You must evaluate all bruises in nonambulatory infants and bruises that are patterned or in unusual distributions or locations. Mongolian spots and cultural practices such as “coining” may be mistaken for bruises caused by abuse. Illnesses that cause bruising may be mistaken for child abuse, including idiopathic thrombocytopenic purpura (ITP), hemophilia, vitamin K deficiency, Henoch-Schonlein purpura, and other coagulopathies. If a bleeding diathesis is suspected, screen with a complete blood count, platelet count, prothrombin time, partial thromboplastin time, von Willebrand panel, and an evaluation for platelet function.