Child Abuse and Neglect

Brett Slingsby, M.D.

Basic Information

Definition

Definition from the Federal Child Abuse Prevention and Treatment Act (CAPTA): any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse or exploitation of a child; or an act or failure to act that presents an imminent risk of serious harm to a child. More specific definitions may be found in individual state criminal and Child Protective Services statutes.

•
Neglect: failure to provide for the basic needs of a child
1. 1.
  
  Physical neglect: failure to provide necessary food, shelter, and supervision
2. 2.
  
  Medical neglect: failure to provide necessary medical or mental health care
3. 3.
  
  Educational neglect: failure to meet educational needs
4. 4.
  
  Emotional neglect: failure to attend to emotional needs, exposure to domestic violence
5. 5.
  
  Abandonment: child left and parents’ whereabouts unknown or parents refuse to care for child
6. 6.
  
  Parental substance abuse: includes prenatal exposure to mother’s use of illicit drugs, manufacture of drugs (e.g., methamphetamine) in the presence of a child, selling or giving drugs to a child, use of mood-altering substance by caregivers that impairs their ability to provide care for a child
•
Abuse: act that causes harm or significant risk of harm to a child
1. 1.
  
  Physical abuse: physical injury or significant risk of injury inflicted by a parent or caregiver intentionally, including in the course of excessive discipline
2. 2.
  
  Sexual abuse: when a child or adolescent is engaged in a sexual act, including sexual exploitation and child pornography
3. 3.
  
  Emotional/psychological abuse: pattern of behavior of caretaker toward a child that impairs emotional development. This includes verbal abuse, cruelty, and threats.
4. 4.
  
  Medical child abuse: unnecessary, excessive, and potentially harmful medical care obtained at the instigation of a caregiver through exaggeration or falsification of symptoms

Synonyms

Child maltreatment syndrome
Physical abuse
Sexual abuse
Battered child syndrome
Shaken baby syndrome
Shaken impact syndrome
Abusive head trauma
Neglect

ICD-10 CM CODES
T74	Adult and child abuse, neglect or other maltreatment, confirmed
T74.02	Child neglect or abandonment, confirmed
T74.12	Child physical abuse, confirmed
T74.32	Child psychological abuse, confirmed
T74.22	Child sexual abuse, confirmed
T76.32XA	Child psychological abuse, suspected, initial encounter
T76.22XA	Child sexual abuse, suspected, initial encounter
T76.12XA	Child physical abuse, suspected, initial encounter
T74.32XA	Child emotional/psychological abuse
DSM-5	Code depends on specific diagnosis

Epidemiology & Demographics

Incidence (In U.S.)

The incidence of child maltreatment is universally underestimated due to children not disclosing abuse and neglect, the diagnosis of abuse being missed, and individuals not reporting abuse and neglect when it is identified. The following data are based on Child Protective Services (CPS) state aggregate as reported in Child Maltreatment 2015. These data typically include only those instances of abuse or neglect that would result in Child Protective Services involvement; therefore, physical or sexual abuse by neighbors, noncaregiving family members, teachers, and siblings may not be counted. In 2015, roughly 700,000 cases of child abuse and neglect were reported. This is a rate of 9.2 unduplicated victims per 1000 children.

•
Types of abuse by percentage (note the total is greater than 100%, since children are often victims of more than one type of abuse).
1. 1.
  
  Neglect: 75%
2. 2.
  
  Physical abuse: 17%
3. 3.
  
  Sexual abuse: 8.4%
4. 4.
  
  Psychological abuse: 6.2%
5. 5.
  
  Medical neglect: 2.2%
6. 6.
  
  Other: 6.9% (e.g., abandonment, threats of harm, congenital drug addiction)
•
For 2015, an estimated 1670 child deaths were caused by abuse or neglect.
1. 1.
  
  Overall annual death rate resulting from abuse or neglect is estimated to be 2.25 deaths/100,000 children.
2. 2.
  
  73% of these deaths were due to neglect alone or in combination with other forms of abuse; 44% were due to physical abuse, alone or in combination.
3. 3.
  
  75% of these children were younger than 3 yr of age with 49% less than 1 yr old.
4. 4.
  
  Most fatalities were directly caused by one or both parents (77%).
5. 5.
  
  Of the states reporting this information, 6.9% of families had parental alcohol abuse, 18% had parental drug abuse, and 14.4% had domestic violence.
6. 6.
  
  Many child abuse fatalities are underreported because of misdiagnosis or variations in state definitions and coding.
•

78% of abused children were victimized by one or both of their parents; however, most data collected by Child Protective Services involve caregivers.

Predominant Sex

There is a slight predominance of girls identified as victims. However, rates vary by age. Boys 5 and under have a higher rate of abuse, whereas girls 6 to 17 have higher rates of abuse. At all ages, boys have a higher child fatality rate than girls (2.48/100,000 for boys and 1.82/100,000 for girls).

Predominant Age

Youngest children (0 to 3 yr old) have the highest rates of victimization, with 27% being younger than the age of 3.

Genetics

No known genetic factors.

Risk Factors

•
Parent
1. 1.
  
  Substance abuse
2. 2.
  
  Mental illness
3. 3.
  
  Intellectual impairment
4. 4.
  
  Parental history of being abused as a child
5. 5.
  
  Young age of parent
6. 6.
  
  Poor knowledge of child development leading to unrealistic expectations
•
Child
1. 1.
  
  Low birth weight or prematurity
2. 2.
  
  Chronic physical disability or illness
3. 3.
  
  Behavioral problems
4. 4.
  
  Developmental delay, intellectual disability, or expressive language disorders
5. 5.
  
  Unplanned, unwanted child
•
Family
1. 1.
  
  Social isolation
2. 2.
  
  Poor parent-child bonding
3. 3.
  
  Stress: unemployment, chronic illness, eviction, arrest, poverty, military deployment
4. 4.
  
  Domestic violence
5. 5.
  
  Nonbiologically related adult male living in household
6. 6.
  
  Previous Child Protective Services involvement
•
Community/society
1. 1.
  
  Limited transportation
2. 2.
  
  Limited day care
3. 3.
  
  Unsafe neighborhoods
4. 4.
  
  Poverty

Diagnosis

•
Disclosures
1. 1.
  
  For sexual abuse, often the only evidence is the child’s disclosure.
2. 2.
  
  Document clearly any disclosures a child makes regarding abuse or neglect.
3. 3.
  
  When speaking with a young child who may have been abused or neglected, it is important to use forensically informed language and not ask direct or leading questions. The child may benefit from a referral to a Children’s Advocacy Center for a forensic interview.
•
Injuries
1. 1.
  Documentation
  1. ▪
    
    Carefully document any injuries identified that may be the result of abuse or neglect.
  2. ▪
    
    Photodocumentation of injuries is essential.
2. 2.
  Concerning history
  1. ▪
    
    The history of injury provided is incompatible with the developmental capabilities of the child.
  2. ▪
    
    Changing history from the caregiver or a history that is different among caregivers.
  3. ▪
    
    The injury is not consistent with the mechanism provided by caregivers.
  4. ▪
    
    No history provided; especially with a nonmobile infant.
  5. ▪
    
    Delay in seeking care for a significant injury.
3. 3.
  Concerning physical injuries
  1. ▪
    
    Patterned bruising (e.g., loop-shaped, two semicircles, rectangular, multiple parallel linear marks) (Fig. E1).
    
    FIG.E1
    
    A variety of instruments may be used to inflict injury on a child. Often the choice of an instrument is a matter of convenience. Marks tend to silhouette or outline the shape of the instrument. The possibility of intentional trauma should prompt a high degree of suspicion when injuries to a child are geometric, paired, mirrored, of various ages or types, or on relatively protected parts of the body. Early recognition of intentional trauma is important to provide therapy and prevent escalation to more serious injury.
    
    From Kliegman RM et al: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders.
  2. ▪
    
    Bruising to the torso, ears, facial cheeks, jawline, upper arms and neck, especially in children under age 4 yr.
  3. ▪
    
    Injury (bruise, burn, fracture, intracranial hemorrhage) in an infant who is not ambulatory and not cruising.
  4. ▪
    
    Patterned burns, such as an impression of the burning object (lighter, iron, cigarette) (Fig. E2).
    
    FIG.E2
    
    Marks from heated objects cause burns in a pattern that duplicates that of the object.
    
    Familiarity with the common heated objects that are used to traumatize children facilitates recognition of possible intentional injuries. The location of the burn is important in determining its cause. Children tend to explore surfaces with the palmar surface of the hand and rarely touch a heated object repeatedly or for a long time.
    
    From Kliegman RM et al: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders.
  5. ▪
    
    Certain fractures (especially in infants) are highly concerning for abuse: metaphyseal, rib, sternum, scapula, vertebral body.
  6. ▪
    
    Any injury that a child says is inflicted.
4. 4.
  Sexual abuse
  1. ▪
    
    Most children who have been sexually abused will have a normal or nonspecific genital examination. A normal genital examination does not mean the child was not abused. History is the most important part of the diagnosis. Forensic interview by a trained professional is recommended, as is an examination by a health care provider experienced in sexual abuse evaluations.
  2. ▪
    
    The identification of a sexually transmitted disease in a prepubertal child who is beyond the neonatal period is highly suspicious and, in some instances, almost diagnostic of sexual abuse. Reporting and further careful investigation are mandatory. Consult current CDC guidelines and a child sexual abuse expert for further guidance.

Differential Diagnosis

The differential diagnosis should include possible medical causes, accidental causes, and abuse.

Bruising

•

Bleeding disorder (idiopathic thrombocytopenic purpura, hemophilia, leukemia, hemorrhagic disease of the newborn, von Willebrand’s disease)
•

Connective tissue disorder (Ehlers-Danlos syndrome, vasculitis)
•

Pigments (dermal melanocytosis)
•

Dermatitis (phytophotodermatitis, nickel allergy)
•

Folk treatment (coining, cupping)
•

Accidental bruises

Burns

•

Accidental burn
•

Impetigo
•

Folk treatment (moxibustion)
•

Dermatitis (phytophotodermatitis)

Intracranial Hemorrhage

•

Accidental trauma
•

Bleeding disorder with minor trauma
•

Perinatal trauma (should resolve by 6 wk)
•

Arteriovenous malformation rupture
•

Glutaric aciduria

Fractures

•

Accidental trauma
•

Osteogenesis imperfecta
•

Rickets
•

Congenital syphilis
•

Osteopenia of prematurity

Sexual Abuse

•

Normal variants
•

Lichen sclerosis et atrophicus
•

Congenital abnormalities
•

Urethral prolapse
•

Hemangioma
•

Nonsexually acquired infection (group A Streptococcus, Shigella)

Workup (Fig. E3)

FIG.E3

Management of suspected child abuse.

*ALT,* Alanine aminotransferase; *BUN,* blood urea nitrogen; *CBC,* complete blood count; *ESR,* erythrocyte sedimentation rate; *INR,* international normalized ratio; *PTT,* partial thromboplastin time; *U/A,* urinalysis.

History and physical examination:

•

Careful history should be obtained and documented from all caregivers separately.
•

Careful history should be obtained from the child. When children are less than 14 years of age, history should be obtained in a forensically informed manner without asking direct or leading questions. A referral to a Children’s Advocacy Center may be indicated.
•

Scene investigation may be necessary and is typically conducted by law enforcement and/or Child Protective Services.
•

Complete head-to-toe physical examination.
•

Sexual abuse: forensic interview and magnified examinations by trained professionals are the standard for evaluation and evidence collection. This is especially important to avoid further psychological or physical trauma to the child.

Laboratory tests to assess for bleeding disorder in the case of children with suspicious bruising. These tests may not be necessary if the abuse was witnessed or if the child has clear patterned bruising or other indicators of physical abuse:

•

CBC with differential and platelets.
•

Prothrombin time, activated partial thromboplastin time.
•

Von Willebrand factor antigen and activity
•

Factor VIII and IX levels
•

Alanine aminotransferase, amylase, urinalysis should be considered in infants or other children with abdominal bruising to look for evidence of internal injury to the liver, pancreas, or kidneys.

Laboratory tests to assess for bleeding disorder in the case of children with suspicious ICH.

•

CBC with differential and platelets
•

Prothrombin time, activated partial thromboplastin time
•

Factor VIII and IX levels
•

DIC panel
•

Consultation with a child abuse expert physician should be strongly considered in children with suspicion of abusive head trauma.

Laboratory tests for sexual abuse:

•

If within 72 hr of acute sexual assault/abuse, a forensic evidence kit (rape kit) can be collected. Swabs are obtained from the oropharynx, areas of skin exposure (use an alternate light source or history provided to identify appropriate areas), genitalia, and rectum to send to the crime lab for DNA and other testing. Also collect samples of foreign hair, blood, saliva, or other tissue if present. Underwear and clothing can also be collected.
•

Per current CDC recommendations, adolescent victims of acute assault should have appropriate specimens collected from sites of penetration or attempted penetration for Neisseria gonorrhoeae and Chlamydia. Nucleic acid amplification tests (NAATs) may be used and are preferred. In females, wet mount and culture or POC testing of vaginal swab for T. vaginalis should also be done. If there is itching, vaginal discharge, or malodor present, wet mount for bacterial vaginosis and Candida should also be done. Serum should be obtained for HIV, hepatitis B, and syphilis testing acutely. If negative, HIV and syphilis testing should be repeated 6, 12, and 24 wk after the assault.
•

Child victims (i.e., prepubertal) should have specimens collected if testing for a sexually transmitted infection (STI) is clinically indicated. Gonorrhea and Chlamydia culture is the gold standard for diagnosis. If needed, vaginal specimens are to be collected by an experienced provider to avoid trauma to the child. Many providers now analyze specimens using urine or vaginal swabs with NAAT testing followed by culture confirmation or 2nd NAAT if any positive results are obtained. The FDA has not approved NAAT testing for gonorrhea and Chlamydia of extragenital sites, so culture remains the gold standard. Testing for sexually transmitted infections (gonorrhea, Chlamydia, T. vaginalis, HIV, syphilis, and hepatitis) should be obtained if the child has a known STI, has symptoms of an STI, or if there is concern for sexual abuse that could result in an STI.

Imaging Studies

Physical abuse:

•

Radiographic skeletal survey for all children with suspicious injuries up to 2 yr. Additionally, a skeletal survey should be considered for any sibling less than 2 yr of age of a child who has been physically abused. Skeletal surveys can be done on children up to 5 yr of age when there are extenuating circumstances. A repeat skeletal survey should be done 2 wk after the initial skeletal survey. Adjunct imaging (MRI, ultrasound, bone scan) may be useful to further define suspicious lesions seen on plain films. Skeletal survey should conform to American College of Radiology Standards.
•

Noncontrast head CT scan or MRI for all children <6 mo of age with concern of physical abuse. Head imaging should be considered for children 6 mo to 1 yr with concern of physical abuse. Children over 1 yr of age should have head imaging if neurological changes or per clinical judgment.
•

When abusive head trauma is identified on head CT, a head MRI should be obtained.
•

Abdominal CT scan if indicated by clinical examination or laboratory evaluation.
•
Box 1 describes the specificity of radiologic findings for child abuse.
BOX 1Specificity of Radiologic Findings for Child Abuse

High Specificity
1. Classic metaphyseal lesions
2. Rib fractures, especially posterior
3. Scapular fractures
4. Spinous process fractures
5. Sternal fractures
Moderate Specificity
1. Multiple fractures, especially bilateral
2. Fractures of different ages
3. Epiphyseal separations
4. Vertebral body fractures and subluxations
5. Digital fractures
6. Complex skull fractures
Common but Low Specificity
1. Subperiosteal new bone formation
2. Clavicular fractures
3. Long bone shaft fractures
4. Linear skull fractures
From Manaster BJ: Musculoskeletal imaging—the requisites, ed 3, Philadelphia, Mosby, 2006.

Treatment

Acute General Rx

•

Stabilize and treat acute medical injuries.
•

Report to Child Protective Services. HIPAA allows reports for suspected child abuse without parental authorization.
•

Report to law enforcement for suspected physical abuse or sexual abuse.
•

Early report to Child Protective Services and/or law enforcement may allow for scene investigation.
•

A safe disposition plan should be determined prior to discharge. This may involve coordination with the multidisciplinary team (physicians, law enforcement, family, and Child Protective Services). Disposition, once medically stable, is dependent on CPS. The child cannot be returned home if the environment is not safe.
•

Physicians should remain available to discuss with investigators. This is often critical to determining the outcome of the case and placement of the child.
•

Because follow-up of adolescent sexual assault victims can be difficult to coordinate, many experts recommend offering empiric treatment for STIs: gonorrhea, Chlamydia, Trichomonas, and bacterial vaginosis. Pregnancy prophylaxis should also be offered. Hepatitis B immunization should be offered if not previously given. HIV prophylaxis is offered in certain situations depending on local epidemiology and type of assault. Consult local infectious disease experts for current recommendations. Repeat evaluation should be done in 2 wk for all victims of sexual assault, especially if they declined empiric treatment. If empiric treatment was not done, STI and pregnancy testing should be repeated at the 2-week follow-up visit.
•

Empiric treatment of child (i.e., prepubescent) who has been sexually abused is generally not recommended. This is especially important if NAATs are used for screening for STIs because confirmation is necessary for any positive results. Careful follow-up within 2 wk and treatment based on culture results are indicated. HIV prophylaxis is offered in certain circumstances according to local epidemiology and risk. Consult with a local infectious disease expert for further recommendations.

Chronic Rx

•

Often depends on CPS and court-ordered interventions
•

Treatment of parental mental illness
•

Treatment of parental substance abuse, including requirements for random drug testing
•

Instruction for parents in behavior management skills, including appropriate limit setting and discipline
•

Anger management classes for parents
•

Trauma-focused cognitive-behavioral therapy is an evidence-based practice for victims of sexual abuse and exposure to domestic violence; useful to include nonoffending parent/caregiver
•
Ongoing individual and family therapy
1. 1.
  
  Parent-child interactive therapy is an evidence-based practice that is used with young children with behavioral problems and parent-child relationship problems
2. 2.
  
  Child-parent psychotherapy is an evidence-based practice that is for young children (<5 yr) who have experienced a trauma and their caregivers
•

May need long-term placement in foster care before it is safe to return home. In extreme cases of abuse, parental rights may be terminated without offering services.

Outcomes

•
Victims of chronic abuse and neglect:
1. 1.
  
  Have higher rates of mental illness (depression, suicide, posttraumatic stress disorder, eating disorders)
2. 2.
  
  Have more cognitive difficulties, often impaired academic performance
3. 3.
  
  Are more likely to become aggressive and have challenging behaviors
4. 4.
  
  Are more likely as adults to have adverse physical health outcomes (cardiovascular disease, cancer, STDs)
•
Victims of abusive head trauma:
1. 1.
  
  One-third die, one-third have severe disability, one-third appear normal in the short term.

Pearls & Considerations

Prevention

•

Home visitation by a specially trained nurse to high-risk families during pregnancy and infancy has shown positive outcomes (Nurse-Family Partnership).
•

Anticipatory guidance at health visits to teach normal developmental expectations and appropriate discipline.
•

Screening to identify at-risk or abused children.
•

Targeted education in the newborn nursery for prevention of abusive head trauma has been shown to be effective.
•

Substance abuse prevention and treatment.
•

Identification and intervention for intimate partner violence.

Ferri – Child Abuse and Neglect