In 2011, an estimated 3.4 million referrals were made to child protective service agencies, involving the alleged maltreatment of approximately 6.2 million children. Children 3 years of age and younger have the highest rates of maltreatment. The total number of children confirmed as maltreated by child protective services was 676,569 in 2011, yielding an abuse victimization rate of 9.1 per 1000 American children. (This statistic is referred to as the “unique count” where a child is counted only once regardless of the number of times the child is substantiated as a victim.) This is the lowest victimization rate over the previous 5-year period. This reflects a drop in rates for physical and sexual abuse, as neglect rates have remained fairly steady. Neglect was substantiated in 78.5% of cases, while 17.6% of cases involved physical abuse, and 9.1% involved sexual abuse. These declines correlate with overall decreases in crime. Additional factors such as improvements in education, reporting, and system responses have also likely played a role in the reduction.

There were 1545 victims of fatal child abuse in 2011 from 51 states, resulting in a rate of 2.1 child abuse deaths per 100,000 children, the same rate as the year prior. Unlike physical and sexual abuse rates, fatality rates have varied over the last 5 years. Based on this information, it is estimated that nationally 1570 children died from abuse and neglect.

Substance abuse, poverty and economic strains, parental capacity and skills, and domestic violence are cited as the most common presenting problems in abusive families. Abuse and neglect of children are best considered in an ecological perspective, which recognizes the individual, family, social, and psychological influences that come together to contribute to the problem. Kempe and Helfer termed this the abusive pattern, in which the child, the crisis, and the caregiver’s potential to abuse are components in the event of maltreatment. This chapter focuses on the knowledge necessary for the recognition, intervention, and follow-up of the more common forms of child maltreatment and highlights the role of pediatric professionals in prevention.

PREVENTION

Physical abuse is preventable in many cases. Extensive experience with and evaluation of high-risk families has shown that the home visitor services to families at risk can prevent abuse and neglect of children. These services can be provided by public health nurses or trained paraprofessionals, although more data are available describing public health nurse intervention. The availability of these services could make it as easy for a family to pick up the telephone and ask for help before they abuse a child as it is for a neighbor or physician to report an episode of abuse after it has occurred. Parent education and anticipatory guidance are also helpful, with attention to handling situations that stress parents (eg, colic, crying behavior, and toilet training), age-appropriate discipline, and general developmental issues. Prevention of abusive injuries perpetrated by nonparent caregivers (eg, babysitters, nannies, and unrelated adults in the home) may be addressed by education and counseling of mothers about safe child care arrangements and choosing safe life partners. Hospital-based prevention programs that teach parents about the dangers of shaking an infant and how to respond to a crying infant have demonstrated some positive results; however, no one effort has been shown to be completely effective. Primary care providers still play an important role in the delivery of anticipatory guidance about abuse prevention.

The prevention of sexual abuse is more difficult. Most efforts in this area involve teaching children to protect themselves and their “private parts” from harm or interference. The age of toilet training is a good time to provide anticipatory guidance to encourage parents to begin this discussion. The most rational approach is to place the burden of responsibility of prevention on the adults who supervise the child and the medical providers rather than on the children themselves. Knowing the parents’ own history of any victimization is important, as the ability to engage in this anticipatory guidance discussion with a provider and their child may be affected by that history. Promoting internet and social media safety and limiting exposure to sexualized materials and media should be part of this anticipatory guidance. Finally, many resource books on this topic for parents can be found in the parenting and health sections of most bookstores.

Efforts to prevent emotional abuse of children have been undertaken through extensive media campaigns. No data are available to assess the effectiveness of this approach. The primary care physician can promote positive, nurturing, and nonviolent behavior in parents. The message that they are role models for a child’s behavior is important. Screening for domestic violence during discussions on discipline and home safety can be effective in identifying parents and children at risk. Societal factors can influence a family’s capacity to parent and care for a child. Issues of crime and safety within a community, the educational system and even the economy may indirectly affect family functioning.

CLINICAL FINDINGS

Child maltreatment may occur either within or outside the family. The proportion of intrafamilial to extrafamilial cases varies with the type of abuse as well as the gender and age of the child. Each of the following conditions may exist as separate or concurrent diagnoses. Neglect is the most commonly reported and substantiated form of child maltreatment annually.

Recognition of any form of abuse and neglect of children can occur only if child abuse is considered in the differential diagnosis of the child’s presenting medical condition. The advent of electronic medical records can make documenting concerns and patterns of maltreatment more accessible for all care team members. The approach to the family should be supportive, nonaccusatory, and empathetic. The individual who brings the child in for care may not have any involvement in the abuse. Approximately one-third of child abuse incidents occur in extrafamilial settings. Nevertheless, the assumption that the caregiver is “nice,” combined with the failure to consider the possibility of abuse, can be costly and even fatal. Raising the possibility that a child has been abused is not the same as accusing the caregiver of being the abuser. The health professional who is examining the child can explain to the family that several possibilities might explain the child’s injuries or abuse-related symptoms. If the family or presenting caregiver is not involved in the child’s maltreatment, they may actually welcome the necessary report and investigation.

In all cases of abuse and neglect, a detailed psychosocial history is important because psychosocial factors may indicate risk for or confirm child maltreatment. This history should include information on who lives in the home, other caregivers, domestic violence, substance abuse, and prior family history of physical or sexual abuse. Inquiring about any previous involvement with social services or law enforcement can help to determine risk.

Physical Abuse

Physical abuse of children is most often inflicted by a caregiver or family member but occasionally by a stranger. The most common manifestations include bruises, burns, fractures, head trauma, and abdominal injuries. A small but significant number of unexpected pediatric deaths, particularly in infants and very young children (eg, sudden unexpected infant death), are related to physical abuse.

A. History

The medical diagnosis of physical abuse is based on the presence of a discrepant history, in which the history offered by the caregiver is not consistent with the clinical findings. The discrepancy may exist because the history is absent, partial, changing over time, or simply illogical or improbable. A careful past medical, birth, and family history should also be obtained in order to assess for any other medical condition that might affect the clinical presentation. The presence of a discrepant history should prompt a request for consultation with a multidisciplinary child protection team or a report to the child protective services agency. This agency is mandated by state law to investigate reports of suspected child abuse and neglect. Investigation by social services and possibly law enforcement officers, as well as a home visit, may be required to sort out the circumstances of the child’s injuries.

B. Physical Findings

The findings on examination of physically abused children may include abrasions, alopecia (from hair pulling), bites, bruises, burns, dental trauma, fractures, lacerations, ligature marks, or scars. Injuries may be in multiple stages of healing. Bruises in physically abused children are sometimes patterned (eg, belt marks, looped cord marks, or grab or pinch marks) and are typically found over the soft tissue areas of the body. Toddlers or older children typically sustain accidental bruises over bony prominences such as shins and elbows. Any unexplained bruise in an infant not developmentally mobile should be viewed with concern. Of note, the dating of bruises is not reliable and should be approached cautiously. (Child abuse emergencies are listed in Table 8–1.) Lacerations of the frenulum or tongue and bruising of the lips may be associated with force feeding or blunt force trauma. Pathognomonic burn patterns include stocking or glove distribution; immersion burns of the buttocks, sometimes with a “doughnut hole” area of sparing; and branding burns such as with cigarettes or hot objects (eg, grill, curling iron, or lighter). The absence of splash marks or a pattern consistent with spillage may be helpful in differentiating accidental from nonaccidental scald burns.

Table 8–1. Potential child abuse medical emergencies.

Head and abdominal trauma may present with signs and symptoms consistent with those injuries. Abusive head trauma (eg, shaken baby syndrome) and abdominal injuries may have no visible findings on examination. Symptoms can be subtle and may mimic other conditions such as gastroenteritis. Studies have documented that cases of inflicted head injury will be missed when practitioners fail to consider the diagnosis. The finding of retinal hemorrhages in an infant without an appropriate medical condition (eg, leukemia, congenital infection, or clotting disorder) should raise concern about possible inflicted head trauma. Retinal hemorrhages are not commonly seen after cardiopulmonary resuscitation in either infants or children.

C. Radiologic and Laboratory Findings

Certain radiologic findings are strong indicators of physical abuse. Examples are metaphyseal “corner” or “bucket handle” fractures of the long bones in infants, spiral fracture of the extremities in nonambulatory infants, rib fractures, spinous process fractures, and fractures in multiple stages of healing. Skeletal surveys in children aged 3 years or younger should be performed when a suspicious fracture is diagnosed. Computed tomography or magnetic resonance imaging findings of subdural hemorrhage in infants—in the absence of a clear accidental history—are highly correlated with abusive head trauma. Abdominal computed tomography is the preferred test in suspected abdominal trauma. Any infant or very young child with suspected abuse-related head or abdominal trauma should be evaluated immediately by an emergency physician or trauma surgeon.

Coagulation studies and a complete blood cell count with platelets are useful in children who present with multiple or severe bruising in different stages of healing. Coagulopathy conditions may confuse the diagnostic picture but can be excluded with a careful history, examination, laboratory screens, and hematologic consultation, if necessary.

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