Keywords
Physical abuse, sexual abuse, neglect
Child maltreatment is a significant public health concern given its prevalence and potential impact on health not only during childhood but also later in life. Each year in the United States, approximately 3 million reports are made to child welfare agencies. These reports represent only a small proportion of the children who suffer from child maltreatment; surveys of adults about their childhood experiences indicate that many cases never come to the attention of authorities. Child maltreatment can cause short-term physical, mental, and developmental health problems, and in extreme cases can be fatal. Research, including the Adverse Childhood Experiences Study, has shown an association between childhood maltreatment and negative adult health outcomes, including physical health problems such as cardiovascular disease and obesity, as well as psychosocial health problems such as depression and substance abuse. A growing body of research demonstrates how toxic stressors in childhood can influence brain development and epigenetics.
Child maltreatment is an act or failure to act by a parent or caretaker that results in death, harm, sexual abuse, or imminent risk of harm. States define child abuse and neglect in civil and criminal statutes. In every state, physicians are mandated by law to report all cases of suspected child abuse and neglect. Child abuse and neglect result from a complex interaction of individual, family, and societal risk factors. Risk factors for maltreatment, such as parental substance abuse, parental depression, and domestic violence in the household, can alert physicians to potential risk and guide development of child maltreatment prevention strategies. However, risk factors should not be used to determine whether a specific patient is a victim of abuse. Child abuse and neglect are often considered in broad categories that include physical abuse, sexual abuse, emotional abuse, and neglect.
Neglect
Neglect is the most common form of child maltreatment and is broadly defined as omissions that prevent a child’s basic needs from being met. Basic needs include adequate nutrition, shelter, education, emotional needs, adequate supervision, as well as medical and dental care. Neglect can impact child physical, mental, developmental, and behavioral health. Potential physical health consequences include abnormal growth, poor dentition, injuries, or ingestions resulting from lack of supervision or environmental hazards, as well as poorly controlled health problems. Child neglect can contribute to developmental delays, risk-taking behaviors or other behavioral problems, school difficulties, emotional problems, as well as attachment problems. Health care providers play an important role in the multidisciplinary response to neglect. Medical interventions could include treating physical health problems such as growth disturbance or injury, simplifying and clarifying treatment plans for chronic conditions, making referrals to community agencies that can assist with concrete needs such as food or transportation, providing developmental assessments and referrals, as well as referring patients to mental and behavioral health specialists. The approach to neglect involves identification of both factors contributing to the neglect, as well as strengths that can be protective factors. Health care providers can play a role in preventing neglect by screening for potential precipitating factors such as parental depression as well as by providing anticipatory guidance on topics such as supervision and injury prevention tailored to the child’s developmental level.
Physical Abuse
Decision-Making Algorithms
Extremity pain
Altered mental status
Alopecia
Physical abuse is second to neglect as the reason for child protective services reports and child maltreatment related fatality. Physical abuse affects children of all ages. In some cases, the diagnosis of physical abuse can be made easily if the child has obvious external abusive injuries or is capable of providing a history of the abuse. In many cases, the diagnosis is not obvious. Abusive injuries are sometimes occult, and children can present with nonspecific symptoms. The history provided by the parent is often inaccurate because the parent is unwilling to provide the correct history or is a nonoffending parent who is unaware of the abuse. The child may be too young or ill to provide a history of the assault. An older child may be too scared to do so or may have a strong sense of loyalty to the perpetrator. History that seems incongruent with the clinical presentation of the child raises concern for physical abuse ( Table 22.1 ).
| A child presents for medical care with significant injuries and a history of trauma is denied, especially if the child is an infant or toddler. |
| The history provided by the caregiver does not explain the injuries identified. |
| The history of the injury changes significantly over time. |
| A history of self-inflicted trauma does not correlate with the child’s developmental abilities. |
| There is an unexpected or unexplained delay in seeking medical care. |
| Multiple organ systems are injured, including injuries of various ages. |
| The injuries are pathognomonic for child abuse. |
Although injury to any organ system can occur from physical abuse, some injuries are more common. Bruises are universal findings in healthy ambulatory children but also are among the most common injury identified in abused children. Bruising location, pattern, and the child’s age/developmental level are important considerations when evaluating bruising. Bruises suggestive of abuse include those that are patterned, such as a slap mark on the face or looped extension cord marks on the body ( Fig. 22.1 ). Bruises in healthy children generally are distributed over bony prominences; bruises that occur in an unusual distribution, such as isolated to the torso, ears, or neck, should raise concern. Bruises in nonambulatory infants are unusual, occurring in less than 2% of healthy infants seen for routine medical care. Occasionally, a subtle bruise may be the only external clue to abuse and can be associated with significant internal injury. Previous sentinel injuries, such as bruising, are common among infants presenting with severe physical abuse. Appropriate evaluation and intervention when non-mobile infants present with unexplained bruising could prevent escalating abuse.
Burns are common pediatric injuries and usually represent preventable unintentional trauma (see Chapter 44 ). Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries ( Fig. 22.2 ) or contact with hot objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges.
Inflicted fractures occur more commonly in infants and young children. Although diaphyseal fractures are most common in abuse, they are nonspecific for inflicted injury. Fractures that should raise suspicion for abuse include fractures that are unexplained; occur in young, nonambulatory children; or involve multiple bones. Certain fractures have a high specificity for abuse, such as rib, metaphyseal, scapular, vertebral, or other unusual fractures ( Fig. 22.3 ). Some metabolic diseases can be confused with abuse and should be considered in the differential diagnosis when appropriate.
