Child Physical Abuse

Christine E. Barron

Carole Jenny

I. Description of the problem. Child physical abuse is defined as acts of commission involving physical violence that results in injuries. These injuries include fractures, bruises, burns, head trauma, and internal injuries. When making the diagnosis of child physical abuse, one needs to consider the age of the child, the plausibility of the history, alterations in the history, delays in seeking medical care, possible mechanisms of injury, potential eyewitnesses, and other possible causes within the differential diagnosis.
- A. Epidemiology. Despite almost certain underreporting, physical abuse accounts for approximately 10.8% of substantiated cases of child maltreatment in the United States. Although certain social and demographic factors have been identified as risk factors, children can be victims of physical abuse regardless of their age, gender, and ethnic and socioeconomic backgrounds. In fact, cases without these identified risk factors are more likely to be misdiagnosed.
- B. Etiology/contributing factors. There are many identified risk factors for child physical abuse, including the following:
  - 1. Unrealistic expectations. Often the lack of understanding a child’s developmental abilities and needs results in caregivers establishing unrealistic developmental and social expectations. These unrealistic expectations can lead to frustration and anger, which can result in abuse.
  - 2. Social isolation. Lack of parenting skills often combine with inadequate parenting models and additional life stressors, and limited resources from family, friends, and community, to increase the risk of abuse.
  - 3. Domestic violence. Children who live in homes where domestic violence is present are more likely to be victims of physical abuse (up to 15 times the national average).
  - 4. Substance abuse. The most frequently reported cause for neglect and abuse of children is parental substance abuse.

II. Making the diagnosis.

A. Signs and symptoms. Child physical abuse has variable presentations and should be considered when
- 1. A child presents with unexplained injury or pattern injuries.
- 2. A nonmobile child present with injuries.
- 3. Illogical or changing explanations are offered by a caregiver to account for an injury.
- 4. A child presents with multiple injuries with different stages of healing.
- 5. There is a delay in seeking medical care.
B. Differential diagnosis. The history and physical examination are helpful in excluding many competing diagnostic possibilities that can mimic child physical abuse. Table 62-1 identifies possible differential diagnoses but is not an exhaustive list.

C. History: interviewing guidelines. Interviews should be conducted in a nonjudgmental manner, acknowledging that everyone’s goal is to simply ensure the safety of the child. Open-ended questions should be asked to determine how an injury occurred. Specific notations should be made for changing histories or if the injury is blamed on the child or the siblings.

1. Interviewing the parents. All caregivers should be interviewed separately. The interview should obtain information regarding the following:

a. The sequence of events that resulted in the injury.
b. Identification of all caregivers during the time of the injury.
c. Any other potential witnesses to the injury, including verbal children.
d. Information regarding past medical history, developmental history, and social history should be obtained.

e. Social history including questions that identify any potential risk factors such as domestic violence, substance abuse, and limited support system.

Record parents information using exact quotes when possible.

Table 62-1. Diagnostic possibilities to consider when evaluating children for possible physical abuse

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