Chapter 35. Child Maltreatment: Neglect to Abuse

The spectrum of parental feelings and behaviors toward children can extend from those that are positive and nurturing to those that are negative, harmful, and culturally unacceptable. At the negative extreme are behaviors that result in child maltreatment, including physical abuse, neglect, and sexual abuse. Although such negative behaviors are often viewed as deviant and separate from normal parenting, in fact, many “normal” parents have feelings and behaviors that may extend to those considered to be maltreatment. Thus, a parent’s anger at the child and use of physical punishment may border on physical abuse, ignoring the child and providing inadequate nurturance or supervision may border on neglect, and close bodily contact and sensual feelings toward the child may border on sexual abuse.

Maltreatment of children includes physical abuse, neglect, sexual abuse, exploitation, and emotional maltreatment. Physical abuse is an act of commission toward the child by a parent or other caregiver that results in harm or intended harm to the child. It can include bruises from a beating, broken bones, or even death. Violence toward children may not result in a serious injury but is still a form of abuse.

The World Health Organization defines physical abuse as “the intentional use of physical force against a child that results in—or has a high likelihood of resulting in—harm for the child’s health, survival, development, or dignity.”1Neglect is an act of omission, such as failure to provide adequate nutrition, shelter, clothing, or supervision; abandonment; or failure to ensure that the child receives adequate health care, dental care, or education. Physical abuse and neglect must be distinguished from unintentional or “accidental” injuries, and health neglect must be distinguished from less serious lapses in attending to a child’s medical care, such as poor adherence to medical recommendations or missing a few appointments for health care.

Sexual abuse is the involvement of children or adolescents in sexual activities that they do not fully understand, to which they cannot give informed consent because of their developmental understanding, and that break societal or family taboos. It includes behaviors such as sexual intercourse, genital fondling, and exposing children to pornography. Exploitation is the use of a child in work or other activities for the benefit of others, such as child labor, commercial sexual exploitation of children, and child trafficking.

Emotional maltreatment, which is the most difficult form of maltreatment to define, includes repeated verbal denigration, belittling, or scapegoating so that the child develops a sense of worthlessness and low self-esteem. Because emotional maltreatment often coexists with other forms of maltreatment, it is difficult to identify and enumerate as a separate type, and thus is substantially underreported. A degree of emotional maltreatment is a component of every form of child maltreatment.

Epidemiology

Although abuse of children and infanticide have occurred over the centuries, pediatric recognition of and concern about battered child syndrome did not begin formally until the 1960s.2 By the 1970s, each state had passed laws requiring the reporting of suspected maltreatment to the state’s child protection agency, and since 1976, there have been annual tabulations of these states’ reports.

Since 1992, the US Department of Health and Human Services has maintained a voluntary national reporting system, the National Child Abuse and Neglect Data System, or NCANDS. NCANDS publishes a yearly report, Child Maltreatment, after collection and analysis of data from participating states. The results of the 2006 Child Maltreatment report identified approximately 3.3 million referrals, including 6 million children under 18 years of age and 1530 deaths due to abuse or neglect. The types of maltreatment substantiated were neglect (64%), physical abuse (16%), sexual abuse (9%), psychological abuse (7%), medical neglect (2%), and other (15%), with some children being victims of more than one type of maltreatment. Reports were approximately equal for males and females.

Of the reported cases, 28.6% were substantiated, meaning that the protective service agency found enough evidence to believe that maltreatment occurred.3 An unsubstantiated report does not necessarily mean that maltreatment did not occur; rather, it means that there was insufficient evidence to meet the state’s definition of maltreatment. In a study of investigated cases that were closed without substantiation, more than one third of closed cases were reported within 2 to 3 years of the original report. Low socioeconomic status was found to be a key predictor of which closed cases were likely to be re-referred.4

Because states have different requirements for reporting, use different criteria to decide whether a report is a substantiated case of maltreatment, and use different approaches to classification and to counting multiple reports on the same child, it is difficult to compare rates from one state to another. Since yearly national statistics were first collected in 1976, reports of maltreatment have tended to increase annually. One explanation for this increase is that changes in society have made it more difficult for parents to care for their children; an alternative explanation, however, is that professionals caring for children have broadened their definition of maltreatment and both parents and professionals have become more aware of the problem and more likely to recognize less serious forms of maltreatment.

In spite of these consistent increases in the overall number of reports annually, there has been a considerable decrease in cases of physical abuse, 36% from a peak in 1992 to 2003.5 One study of abusive fractures at a major pediatric hospital revealed a significant decline in the proportion of fractures due to abuse from 1979–1983 to 1991–1994 and to 1999–2000. The authors speculated that recognition of less serious forms of child abuse plus the availability and provision of services to high-risk families may have accounted for the shift.6 Similarly, rates of substantiated cases of sexual abuse peaked in the early 1990s but have since declined steadily, 47% from a peak in the mid 1990s to 2003. The authors speculate that possible explanations for these marked decreases include improvements in the economy, increased rates of incarceration of criminals, increased availability and dissemination of effective psychiatric medication, and a possible generational shift in behavior and attitudes.5 Rates of neglect, on the other hand, have remained fairly stable and high since the early 1990s. Whether this stability reflects a lack of change in actual rates of neglect or a shift in what defines neglect is not known.

Most maltreatment occurs in the child’s home. In 2006, nearly 80% of perpetrators of child maltreatment were parents, 58% of perpetrators were women, and more than half of the perpetrators (60%) were found to have neglected their children.3 In a study of child deaths due to inflicted injuries, over 70% of known perpetrators were male.7 Perpetrators of sexual abuse are almost all males, and between 20% and 25% of them are juveniles, 16 years old or younger. The child who has been sexually abused most often knows the perpetrator, who may be the father, stepfather, another male relative, or a family friend. The small proportion of sexually abused children who do not know the perpetrator are usually older children or adolescents who are victims of forceful sexual assault or rape.

Reported cases of maltreatment are those that are recognized by clinicians and therefore may substantially underestimate the true rate of maltreatment that occurs in society. For example, it is thought that sexual abuse of boys is common but likely to be both underrecognized and underreported.8 Two additional epidemiologic approaches have been used to determine the true prevalence of the problem. First, parents have been interviewed to determine both their behaviors toward their children and their knowledge of their children’s victimization by others. A telephone survey of mothers in North Carolina and South Carolina found dramatically higher reported rates of physical abuse and sexual victimization than were reflected in local child protective services data. The incidence of physical abuse as determined by maternal survey was 40 times higher than that of official child protective services reports, and the reported incidence of sexual abuse was 15 times greater.9 Interviewing parents is a method that has also been used internationally to determine incidence when child protective services data are scarce or absent. In a cross-national collaborative study, investigators in Chile, Egypt, India, and the Philippines queried mothers between 1997 and 2003 about discipline practices. During the 6 months prior to being asked, mothers reported that they hit a child with an object not on the buttocks at rates between 45 and 36%. In Egypt, beating a child within the last 6 months reportedly occurred at a rate of 25%, while in rural India, 10% of mothers reported kicking a child.10

A second approach surveyed adults about how they were treated as children. In a random survey of 2869 young adults conducted in the United Kingdom in 1998 and 1999, 16% of the respondents reported that they had experienced some form of child maltreatment. Seven percent of respondents reported experiencing physical abuse, 6% reported emotional abuse, 6% reported absence of care, 5% reported absence of supervision, and 11% reported sexual abuse involving contact.11 With respect to serious physical abuse, it is to be noted that most serious physical abuse occurs in children 3 years old and younger. Therefore, it is possible that adults recalling their own childhoods may be likely to underestimate their abuse histories.

Rates of reported past sexual abuse vary based on the population sampled, the type and number of questions asked of adults, and the operational definitions used. A review of 19 studies of adults completed in the United States or Canada found that the rates of sexual abuse reported by men were 3% to 16% and by women 3% to 62%. The review determined that reasonable estimates of the rates of sexual abuse of girls under age 18 years is 20% and of boys under 18 years is 5% to 10%.12

The causes of child maltreatment are complex, and no single factor can be identified as certain to lead to child maltreatment. Belsky wrote that “there is no one pathway to disturbances in parenting; rather, maltreatment seems to arise when stressors outweigh supports and risks are greater than protective factors.”13 A helpful framework for understanding what may place a child at risk for maltreatment involves the construction of an ecological model consisting of child, parent, family, and societal factors. The factors associated with the occurrence of abuse and neglect are listed in Table 35-1.

Child factors include the age of the child because younger children, those under 3 years of age, are significantly more likely than older children to die from physical abuse or neglect. Younger children are also most dependent upon caretakers for meeting basic human needs and are thus most vulnerable to neglect. Children born of unwanted pregnancies, disabled children, multiple births (eg, twins), and premature infants are at an increased risk of child maltreatment.

Parent factors that can lead to abuse or neglect include young maternal age and abuse of alcohol or drugs.14 Some parents have limitations that can seriously interfere with parenting, such as a parent with mental retardation who may lack the basic skills necessary to provide appropriate food or stimulation to a child, or a depressed mother who may lack the energy and vigilance to supervise the child adequately. It is not likely that any single parent factor will lead to abuse. For example, although there is a strong association between a history of abuse as a child and abusing one’s own child (the “intergenerational transmission of abuse”), the majority of parents who were abused as children do not abuse their own children.15

Family factors associated with abuse and neglect include single parents, socially isolated families, families in which the household composition is frequently in flux, and families in which there are many children under the age of 5 years. Intrafamilial violence, such as intimate partner violence, is an independent risk factor for subsequent child maltreatment.16

Societal factors that contribute to child maltreatment are poverty and poor community resources and infrastructure, such as lack of adequate jobs and poor education. Because reported cases of maltreatment come from all social classes, the fact that abuse and neglect are reported more commonly in families who are poor and less educated suggests that these factors contribute heavily to the ability (or failure) of a parent to form an adequate and protective relationship with a child. Other neighborhood-level factors found to have an association with maltreatment include male unemployment rates, residential turnover, and median residential property value.17

On the other hand, reporting bias can obscure the role that socioeconomic factors play as risk factors for abuse. For example, in a study of young children (1 and 2 years old) evaluated for long-bone or skull fractures, minority children who had accidental injuries were evaluated and reported for suspected abuse at higher rates than were nonminority children.18 Similarly, in a study of cases of abusive head trauma that were initially missed by medical providers, cases in white children and those living with both parents were significantly more likely to be missed than were cases in minority children.19

Pathogenesis

Within this ecological framework, clinicians have focused on the nature of the relationship between a parent and a child. Two interrelated ways of understanding this relationship are an examination of a parent’s attitudes and feelings about a child and the quality of the attachment between a parent and a child.

Four types of attitudes and behaviors are seen in abusive or neglecting parents. The first is an inappropriate parental expectation of the child, such as expecting a newborn to sleep through the night or an 8-month-old to be toilet trained. The second is a failure of empathy between parent and child, or an inability of the parent to understand and participate in the child’s emotional experience and ideas. This failure may stem from a low self-worth on the part of the abusive parent, as the degree of self-worth is a predictor of how a person will treat and respond to others. The third is a placement of inherent value on the use of physical punishment. Fourth, abusive or neglecting parents may reverse the parent-child roles and see children as the source for family comfort and happiness. When faced with the persistent neediness and dependence of children, parents who expect their children to care for them can experience profound disappointment, which can lead to further abuse.20

An assessment of the quality of the relationship between the parent and the child also is helpful in understanding the factors that lead to abuse and neglect. Secure attachment between a parent and a child is a protection against abuse or neglect, and a poor or failed attachment is a risk factor. Sensitive and responsive parents help ensure attachment, while parents who are insensitive, rejecting, or inconsistent threaten a successful attachment.21 Parents may be unable to be sensitive, accepting, and consistent for a host of reasons, including their own parents’ failure to provide a secure nurturing environment to them or other traumatic experiences that led to mental health problems such as depression or substance abuse.

It is likely that a constellation of factors, such as a combination of ecological risk factors, a parent’s negative feelings about a child, and a poor parent-child attachment, must exist for maltreatment to occur.

It is important to recognize that risk factors for child maltreatment tend to vary with the type of maltreatment. Physical abuse, for example, typically occurs when a parent loses control and injures a child. In cases of both abusive head trauma and abusive fractures, males are significantly more likely than females to be the perpetrators.22,23 Parents who use and value physical discipline at baseline are more likely to experience such a loss of control, and use of physical punishment is a known risk factor for more serious physical abuse.24 Similarly, predictably challenging periods in a child’s development are frequently linked with physical abuse. For example, normal infant crying that peaks within the first months of life is associated as a prime trigger for inflicted traumatic brain injury.25 Another trigger for physical abuse is toilet training and the inevitable demands that this period can bring. An important factor to consider is parental drug or alcohol abuse, which can have profound negative influences on parents’ abilities to care for their children. Substance abuse is also an important precursor to neglect. National spikes in drug use, such as the epidemic of crack cocaine in the 1980s and 1990s, result in a marked increase in the incidence of neglect.

The sexual abuse of children is more difficult for most clinicians to understand than is the occurrence of physical abuse or neglect. The 2 prerequisites for this form of maltreatment include sexual arousal to children and the willingness to act upon this arousal.26 Factors that may contribute to this willingness include alcohol or drug abuse, poor impulse control, and a belief that the sexual behaviors are acceptable and not harmful to the child. The past history of the perpetrator (eg, having been sexually abused during childhood), the particular vulnerability of the child (eg, a developmental delay), and a circumstance that enables the perpetrator to have increased contact with the child (eg, a mother who is hospitalized) all contribute to the likelihood that sexual abuse may occur. Recent work suggests that while identified perpetrators of child sexual abuse may have levels of generalized empathy comparable to nonperpetrators, perpetrators are likely to lack empathy specifically for their child victim. This finding suggests that even in an adult capable of empathy, a failure or suspension of understanding and regard for a child victim is an important component of sexual abuse.27

Like other forms of family violence, the maltreatment of children usually occurs in the privacy of a home and is seldom witnessed by another person. Because the child is often too young or too frightened to explain what happened and the correct history often is not known or not provided by the parents, clinicians should be aware of suspicious histories and recognize the typical behaviors and physical findings of maltreated children. Although 3 types of maltreatment (physical abuse, neglect, and sexual abuse) are described separately, a child may suffer from more than 1 type.

Physical Abuse

Five types of histories should raise the suspicion of abuse: (1) a child with a serious injury, such as a fracture, but no history of preceding trauma (eg, “I noted that his arm was limp”); (2) a history that is inconsistent with the severity, mechanism, or timing of the injury; (3) a delay in seeking medical care for a significant injury; (4) a history that changes during the course of the evaluation; and (5) a history of recurrent injuries, especially those that are poorly explained.

Children who have been abused display a variety of behaviors. They may be excessively fussy, frightened, or depressed due to recurrent pain, maltreatment, and the impact of living in a threatening and unpredictable environment. Older children may demonstrate role reversal in their interactions with their parents: Instead of the parent caring for the child’s needs, the children learn to be particularly sensitive to the parents’ needs and, in part, to avoid being hurt, may provide care for the parents. Such children may attempt to be well behaved around adults in order to avoid offending them and being punished. Some children who have been abused repeatedly do not cry during medical procedures, such as blood drawing, because crying at home may have resulted in additional punishment.

The spectrum of physical abuse extends from a single episode, such as a slap on the face, to recurrent and more serious injuries. Children who sustain injuries from abuse that are mistakenly diagnosed as unintentional injuries are at substantial risk of being more seriously hurt or even of dying from abuse. Soft tissue injuries are the most common clinical manifestation of physical abuse. These include hand marks from slapping; bruises from punches; linear and curved marks from belts, cords, or switches; and bite marks. In evaluating injuries to the skin, it is important to consider the child’s developmental level. For example, 1 year olds who are learning to walk often fall forward and bruise their face, and it is not uncommon for preschool children to bruise their shins. Studies of bruises in young children have demonstrated that it is unusual to see bruises in children who are not cruising.28 “Black eyes” and bruises around the ears, in the genital region, or on the posterior surface of the body are highly suspicious of abuse at any age. Bruises result from bleeding into the skin or subcutaneous tissues. Fresh bruises are usually tender and swollen, with maximum swelling in 1 or 2 days. Bruises change color from deep purple/red to green to yellow/brown. The rate of these changes depends on the depth of the bruise, the amount of bleeding, the location of the injury, possible drugs the child has taken, or the inherent clotting ability of the child. Because of the many factors involved in bruise progression, dating an injury based on the appearance of a bruise is inexact.29

Burns are another common type of abusive injury. These can include scald burns from hot liquids or burns from hot objects, such as irons, stoves, or cigarettes. Although burns that are due to abuse are often difficult to distinguish from unintentional injuries or those due to neglect, the location and pattern can be helpful. Children who have been immersed in hot water may have bilateral burns of the upper or lower extremities or burns of the buttock or back. These inflicted burns often have a sharp demarcation between the injured and noninjured skin. A child who has been held in hot water in a tub may have a spared area of buttocks, as a result of the area having been pressed against the tub. In contrast, nonabusive scalds tend to be asymmetric from one extremity to the other, have less sharply demarcated borders, and reveal splash marks that indicate the child tried to avoid the injury.30 Other commonly occurring unintentional scald burns occur when young children spill containers of hot liquid on themselves.

Cigarette burns are another type of suspicious injury. An isolated, unintentional cigarette burn, which tends to be superficial, can occur when a young child comes in contact with a cigarette held by an adult. In contrast, inflicted cigarette burns tend to be deeper, are located on areas to which accidental contact would be unlikely, and may be multiple.

Head injuries are the most common cause of death due to child abuse. A recent epidemiologic study found the incidence of abusive head trauma to be 32.2 per 100,000 infants between 0 and 12 months old.31 Abuse can occur from shaking alone or from a combination of shaking and blunt impact. An analysis of perpetrator admissions of abusive head trauma indicates that shaking is the most common mechanism of abusive head trauma.32 Because in most cases the actual mechanism of injury is not observed, the use of a general term such as abusive head trauma is preferable to a specific term like shaken baby syndrome, which implies a single mechanism of injury. An important secondary mechanism involved in abusive head trauma is hypoxic ischemic injury that occurs as a result of the initial trauma.33,34 Abusive head trauma can result in intracranial bleeding due to repeated accelerations and decelerations of the brain that produce shearing of the bridging veins (resulting in subdural or subarachnoid hemorrhages) and retinal hemorrhages, which often can be extensive, involve different layers of the retina, and extend to the periphery (see Chapter 587).35,36

Children with abusive head injuries may present with seizures, signs of increased intracranial pressure, coma, or apnea and cardiac arrest. Often, there are other signs of child abuse, such as bruises or healing fractures. Rib fractures can be seen in conjunction with abusive head trauma; these fractures occur when the infant is held around the thorax, and the abuser squeezes the chest causing anteroposterior compression and posterior rotation.37 Because rib fractures are usually not visible on chest radiographs until callus formation has begun to occur 10 to 14 days after an injury, the presence of an acute head injury and healing rib fractures indicates that the child has been injured on at least 2 occasions.

In head injuries due to abuse, there usually is no clear history of severe head trauma to direct the clinician toward the right diagnosis. In contrast, when children sustain serious unintentional intracranial injuries, such as those due to major falls or automobile accidents, there is a clear history to explain the injury, and retinal hemorrhages occur much less commonly. Most minor falls from heights of less than 36 inches do not result in serious head injuries, although skull fractures, with and without small, transient, and localized areas of subdural bleeding near the fractures, as well as epidural bleeding, can occur. Scalp hematomas are more common in children who sustain accidental falls than in children with abusive head injuries.36

Fractures of bones are another common type of abusive injury in young children. In a series of 215 children under 3 years of age with fractures, 24% were believed to be due to abuse.38 The highest occurrence of abusive fractures is in children under 1 year of age. Skull fractures that are depressed, branching, or diastatic have been associated with physical abuse; the most common type of skull fracture, however, found as a result of abuse (as well as with unintentional injuries) is a linear fracture of the parietal bone.38,39 Fractures of the humerus (especially midshaft or proximal) and fractures of the femur (especially in children under 1 year of age) should be considered suspicious of abuse. In contrast, a 2- or 3-year-old child may have a supracondylar fracture of the humerus from a fall on an outstretched arm or a spiral fracture of the femur or tibia from falling and twisting. Whether the fracture is spiral or transverse is not by itself diagnostic for abuse. Rather, a careful consideration of the nature and severity of the injury, the proposed mechanism of injury, and the developmental abilities of the child should be undertaken.40 Two types of fractures more specific for abuse are classic metaphyseal, or bucket handle, fractures and rib fractures, particularly those that are posterior and adjacent to the spine. Several studies have indicated that rib fractures are unlikely to occur during cardiopulmonary resuscitation in young children.41

Other types of injuries that should raise the suspicion of abuse are intentional poisonings and abdominal injuries (including lacerations of the liver, spleen, or intestines). Children with abdominal injuries are at particular risk of hypovolemic shock and even death when the internal injury is unrecognized and the history of blunt trauma is not provided by the caregiver. Multiple abdominal injuries, a high severity of injury, and a delay in seeking care should prompt particular concern for abuse.42

An additional form of abuse that is often difficult to recognize is medical child abuse, in which a parent (usually the mother) fabricates symptoms of an illness in the child resulting in an extensive medical evaluation, or causes the child to be ill by poisoning or some other means (eg, injecting contaminated fluid into an intravenous line) in order to assume the sick role by proxy. Caregivers who perpetrate medical child abuse for the gratification of having a sick child are given a psychiatric diagnosis of Munchausen syndrome by proxy (MSBP), or factitious disorder by proxy. Medical child abuse has a high fatality rate because diagnostic efforts are focused on the sick child, and MSBP is often recognized too late in the caregiver. The most common presentations of medical child abuse are seizures, apnea, diarrhea, and fever.43,44 Studies of MSBP have focused on 2 other conditions—apparent life threatening event and multiple sudden infant death syndromes in families—that can be caused by abusive behaviors, such as suffocation or strangulation. In a British study of 39 children (age range of 2–44 months) who were referred because of suspicion of an induced illness, 36 presented with apparent life-threatening event. In the 39 families, 12 previous children had died suddenly and were labeled as deaths due to sudden infant death syndrome. Covert video recordings in the hospital revealed abuse in 33 cases, and there was documentation of suffocation in 30 of these children. In 11 of the cases of suffocation, the children had bleeding from the nose and/or mouth.45 When more than 1 infant in a family dies unexpectedly and is labeled sudden infant death syndrome, child abuse and other causes, such as metabolic ones, need to be considered. Educational disabilities, behavioral problems, and psychiatric disorders have also been fabricated by parents who were ultimately diagnosed with MSBP.46,47

Neglect

Neglected children are recognizable by the chronic failure of their parents to provide adequate physical care or ensure appropriate medical care or education, or when the child is brought for medical attention because of an injury or ingestion due to failure of adequate supervision. Worrisome histories include evidence of inadequate provision for the child’s basic needs, inadequate supervision, or a delay in seeking medical care. It should be noted, however, that neglect in its less obvious forms can be quite difficult to define.48

In infants and young children, a common manifestation of neglect is poor growth and developmental delay due to decreased nutritional intake and understimulation. Such children, who are labeled as having nonorganic failure to thrive, often are recognized first because of poor weight gain or because they fall off the growth curve. Initially, the child’s length and head circumference may be relatively spared, but if the nutritional deprivation continues, these parameters also are affected. The general pattern of growth for decreased nutritional intake, regardless of the cause, is for weight to be most affected and head circumference least affected; this pattern can be ascertained by plotting each of the growth parameters on the 50th percentile curve and determining the child’s age at the respective points (eg, the child’s “weight age”). In many children whose failure to thrive is due to neglect, there also is a developmental delay, particularly affecting the child’s language and social interactions. Such children may appear listless, have a flat affect, and demonstrate indiscriminate attachment behaviors. Older children who are neglected often appear as emotionally needy. They may be depressed or adultlike in their behaviors as a result of having to learn to care for themselves. Acute problems, such as ingestions, burns, or injuries from falls, are common presentations in neglected children and should be distinguished from abuse or unintentional injuries.

Sexual Abuse

Children who have been sexually abused generally come to the attention of clinicians because the child has told an adult about an uncomfortable experience (eg, “My uncle touches me down there, and I don’t like it”), the parent becomes concerned about the child’s behaviors (eg, sexualized acting out) or symptoms (eg, vaginal discharge), or a genital or anal abnormality is noted on physical examination.

Although the child’s statement is one of the clearest indications that the child has been sexually abused, a very young child may have difficulty explaining what happened, and an older child may retract a relatively clear statement after the child begins to understand how upsetting the disclosure is to the family. In certain circumstances, such as disputes about custody or visitation, it may be particularly difficult to determine the truthfulness of the child’s statements because of the complexities of the relationships in the family.

Children who have been sexually abused may demonstrate a variety of behaviors and symptoms. Many are nonspecific and are seen in response to other childhood stresses as well, such as poor school performance, generalized anxiety, encopresis, or suicidal gestures. Others are more suggestive, but not specific, such as excessive masturbation, sexualized behaviors, vaginal discharge or bleeding, or rectal bleeding. Even a symptom such as vaginal discharge, however, has a low likelihood of being due to sexual abuse. In several studies of premenarcheal girls with the complaint of vaginal discharge, the most frequent diagnosis was poor hygiene, and sexual abuse was found in less than 5% of cases.49

Although all children suspected of being sexually abused should have a complete physical examination, most are likely to have normal findings on examination. In a study of 2384 children referred for possible sexual abuse to a tertiary referral center, the investigators found that only 4% of the children had an abnormal genital or anal examination at the time of evaluation.50 A normal examination does not rule out sexual abuse, as there may have been no injury to the genital area or, if there was an injury, it might have healed without leaving any signs. In cases in which there has been a conviction of a perpetrator, it is unusual for victims to have an abnormal physical finding. In a series of 236 children where the perpetrators were convicted, 23% of genital examinations of girls and 7% of anal examinations of all children were considered abnormal or suspicious.51 In a study of 36 adolescent girls who became pregnant as a result of suspected sexual abuse, only 2 of the 36 girls had definitive genital findings of penetration.52

Considerable research in the last several years has been conducted to define normal and abnormal genital and anal anatomy in prepubertal children. The appearance of the hymen is often thickened in early childhood because of the effects of maternal estrogen in utero; in preschool and school-age girls, the hymenal tissue becomes thinner until the effects of estrogen during puberty result in a thickening of the tissue and the development of redundant folds. Studies of normal prepubertal girls have described the shapes of the hymen as crescentic, annular, and fimbriated (or redundant) and have noted the frequency of normal variations, including hymenal mounds, intravaginal ridges, and adhesions of the labia minora.53,54

Lacerations or bruising of the hymen, perianal lacerations extending deep to the external anal sphincter, healed hymenal transections, and a missing segment of hymenal tissue are findings with a high specificity for penetrating trauma. Transections and missing segments of hymenal tissue should persist when the child is examined in the prone, knee-chest position. Scarring, such as of the posterior fourchette or perianal area, may be indicative of previous trauma.55

Anal findings, such as acute fissures, also can be seen in sexually abused children. Normal findings in the prone, knee-chest position include skin tags in the midline, fan-shaped areas in the midline superiorly, perianal erythema, venous congestion, and anal dilation up to 2 cm.56 Children who sustain anal trauma as a result of sexual abuse may not have abnormalities on examination if the event is not acute. In a study of children with documented anal injuries followed from acute injury to healing, 29 of 31 children healed completely, with scar formation in only the 2 cases requiring acute surgical repair.57

Children who have been sexually abused may acquire a sexually transmitted infection, and adolescents are at risk of becoming pregnant. The most common infections are gonorrhea and chlamydia. Also, there have been several reports of human immunodeficiency virus (HIV) infection that were transmitted by sexual abuse. The confirmed infection of a prepubertal child with gonorrhea, syphilis, or chlamydia, if not perinatally acquired is thought to be diagnostic of sexual abuse and must be reported. Rarely, gonnorhea can be transmitted in a nonsexual manner. Similarly, the presence of HIV infection in a prepubertal child, if not perinatally or transfusion acquired, is diagnostic of sexual abuse and must be reported.58 Human papillomavirus (HPV) presents a special case in the evaluation for possible sexual abuse. Although previously believed to be to the result of perinatal transmission, HPV is either rarely vertically transmitted or never vertically transmitted.59,60 Recent epidemiologic data suggest that many preadolescent children acquire HPV from nonsexual horizontal transmission, either by autoinoculation if a child has common skin warts or horizontally from nonabusive contact by a person who has common warts, and that the likelihood of sexual abuse as a possible cause increases with age.61,62 History and full medical evaluation are of particular importance in ascertaining the possibility of sexual abuse in a child with HPV.

When evaluating a child for suspected maltreatment, the clinician must decide whether an alternative explanation, such as an unintentional injury, a medical problem, or an acceptable parental behavior, can help explain the child’s problem. The evaluation should include a complete history, careful physical examination, appropriate laboratory tests, and full documentation of the findings. In many settings, these tasks are divided among professionals so that a physician might obtain a medical history and conduct the examination while a social worker obtains a psychosocial history. When available, community-based or hospital-based child-protection teams can guide clinicians in their assessments and offer specialized evaluations or treatment services.

A careful history concerning the events leading to the child’s condition, the child’s health status and development, and the family’s strengths and weaknesses can help determine what happened to the child and the important contributory factors (Table 35-2). Data should be collected from the parents, from the professionals who know the child and family, and from the child directly.

It is not uncommon for caregivers who were not actually present when the child was injured to report about the events causing the injury as if they were present. Careful questioning can help distinguish eyewitness accounts from secondhand information. It is important to note inconsistencies in reports (either from different caregivers or, over time, from the same caregiver) about how an injury occurred or how an injury/behavior evolved. Sometimes, however, inconsistencies may reflect different styles of history taking or variable documentation rather than inconsistencies because of intentionally confusing and misleading information. When maltreatment is being considered, supportive interviews of the parents alone and together may result in an admission of an abusive episode, a chronic pattern of neglect, or failure to nurture the child adequately.

When failure to thrive due to neglect is suspected, a careful feeding history should be obtained to estimate the child’s caloric intake and to determine how the formula (or food) is prepared, what is offered to the child and how the child responds, whether feeding problems have occurred in the past, and what the parental concerns and fears are. Information also should be obtained about the child’s developmental milestones, temperament, affect, and interactions with parents and others.

When sexual abuse is suspected, the parents must be asked explicitly about what the child said as well as about the child’s symptoms, such as vaginal discharge or bleeding, rectal bleeding, constipation, encopresis, sexualized behaviors, or unusual or recurrent fears. If possible, information should be gathered from sources other than the child in order both to minimize additional trauma to the child and to prevent contamination of information necessary to the investigation and possible prosecution of a crime. Important additional data to be obtained about the family include whether the parents are separated or divorced, what kind of visitation schedule exists, and whether there is a dispute about custody or visitation.

After a referral to child protective services is made, developmentally appropriate children suspected of being sexually abused are likely to be interviewed directly about what may have happened to them by a trained forensic interviewer. This interview should be done with the child alone, and the interviewer should be skilled at such assessments and careful to avoid leading questions. An evidence-based protocol for forensic interviews has been developed and is in widespread use. Interviews are usually conducted behind a one-way mirror with representatives of child protective services and law enforcement observing. To help young children describe what may have happened to them, interviewers have used stimulus props, such as anatomic drawings or anatomically detailed dolls, for clarification of a child’s initial statements.

The physical examination should focus on the child’s growth, development, affect, and interactions with parents and health professionals as well as on the state of hygiene, signs of new and old injuries, and signs of sexual abuse. Physical findings such as extensive dental caries and severe diaper dermatitis may be indicative of neglect.63

The examination of children suspected of having been sexually abused should include a careful inspection of the genitals and anus. The clinician should remain alert to signs that might point to an alternative diagnosis. In girls, the genital examination is best performed in the supine position; when abnormalities of the hymen are noted, the child also should be examined in the prone, knee-chest position to determine whether the abnormality persists.

To visualize the hymen, the examiner can use 2 maneuvers: labial separation—separating the labia majora and pulling down at an angle of 45 degrees—and labial traction—gently pinching the labia majora and pulling out and toward the examiner. Girls with suspicious findings should be examined by an expert examiner who uses a videocolposcope or photocolposcope, which provides magnification and the ability to document the findings. During the examination, careful attention must be paid to avoid any additional trauma to the child who may have been sexually abused. A clear explanation of the nature of and purpose of the examination, as well as the presence of a supportive adult, will help to assure the child’s comfort in this setting.58

In some cases, more extensive diagnostic studies are indicated. For children with serious head injuries, an ophthalmologic examination should be performed to determine whether retinal hemorrhages are present. This examination is best performed on dilated pupils by a pediatric ophthalmologist or an ophthalmologist with pediatric experience. The location and extent of retinal hemorrhages have been found to be very helpful in differentiating accidental from inflicted head trauma.36 A child’s course can be followed clinically and with computed tomography scans as necessary; magnetic resonance scans can be helpful in delineating the exact injuries and dating the age of an intracranial bleed. Where there is a suspicion of abuse or neglect in a child under 2 years old, a skeletal survey can reveal unsuspected recent or old fractures as well as provide information about an underlying medical problem, such as osteogenesis imperfecta. In children in whom abuse is highly suspected, a follow-up skeletal survey 2 weeks after the first is also indicated. The rate of detection of unsuspected fractures depends on the sample investigated; in one study of children under 36 months of age with fractures, 31% of skeletal surveys were positive.38

In children with bruises or bleeding, a complete blood count, a platelet count, prothrombin time, partial thromboplastin time, international normalized ratio, and bleeding time are appropriate screens. When suspected clinically, more detailed tests for bleeding disorders should be ordered.63 Liver enzyme tests may be a helpful screen for occult liver injury.64

In children with failure to thrive, a careful history, physical examination, feeding observation, and home visit are significantly more likely than laboratory testing to reveal the cause of poor or failed growth.65 Any additional tests to search for an underlying disease should be directed by concerns noted in the history or abnormalities noted on the physical examination.

When a child is evaluated within 72 hours of an episode of suspected sexual abuse, forensic evidence collection, including body swabs; clothing and linen collection; and hair, saliva, and blood samples may be indicated.58 Tests for sexually transmitted diseases, including gonorrhea, chlamydia, syphilis, hepatitis C, and HIV infection, should be obtained in children when the abuse might have resulted in transmission of such a disease. In adolescents, a pregnancy test may be necessary.

Detailed documentation of the data collected, with direct quotations of the parents’ or child’s statements, and a clear description of the child’s injuries both in writing and with sketches is important. Many states have a specific form for recording information from an examination to determine whether sexual abuse has occurred. Photographs of the child’s injuries, labeled with the date and the child’s name and record number, can be very helpful.

The most important first step for the pediatric clinician who has identified suspected abuse or neglect of a child is to make a formal report to child protective services.

Differential Diagnosis

The most common distinction that must be made in a case of suspected maltreatment is between abuse or neglect and an unintentional injury or inadequate nurturance. In addition, a variety of alternative explanations should be considered in the differential diagnosis. Bruises must be distinguished from birthmarks (eg, Mongolian spots), coagulation abnormalities (eg, idiopathic thrombocytopenic purpura), dermatitis (eg, phytodermatitis), or the result of folk medicine practices (eg, coin rubbing). Burns due to maltreatment can be confused with skin diseases that develop bullae, unintentional scalds, or unusual burns, such as laxative-induced dermatitis of the buttocks due to ingestion of senna.66 Cigarette burns may be confused with impetigo. When evaluating a young child with a fracture, the clinician must consider the possibility of an underlying disease such as osteogenesis imperfecta, rickets, or congenital syphilis. In such cases, there usually are other clinical signs or radiographic features to help make the correct diagnosis.

When evaluating concerns of sexual abuse, the clinician should consider the possibility of a false allegation in the differential diagnosis. In young children, particular attention should be paid to the use of open-ended or forced-choice questions and to avoiding the overinterpretation of vague statements, such as “He touched me.” Also, clinicians should consider the possibility of a false allegation if the child has a serious mental health problem; if the child is caught in a bitter dispute, such as a custody battle, between parents; or if the child’s statements about what happened have important inconsistencies or are vague and lack details.

In cases of suspected sexual abuse, the examiner must identify abnormalities that are secondary to trauma due to sexual abuse from normal variations of anatomy. Physical conditions also can be mistaken for sexual abuse. Common examples are lichen sclerosis, which can cause thinning of the skin and subepidermal hemorrhages of the vulva and perianal area, and prolapsed urethra, which can mimic acute trauma. Straddle injuries, which usually have a clear history of a fall and are associated with external injuries of the female genitalia, also must be distinguished from sexual abuse. A foreign body, such as toilet paper in the vagina, can present with foul smelling, serosanguineous fluid and can be confused with sexual abuse.

Children with failure to thrive due to neglect must be distinguished from children who are not growing well because of an underlying disease (eg, cystic fibrosis or a congenital infection) or whose poor nutritional intake is due to an interactional problem between the primary caregiver (usually the mother) and the child. For example, if an infant is fussy and spitting during feeding, a vulnerable mother may not enjoy feeding her child, lose patience, and thus provide inadequate calories.

There are 6 important steps in the management of suspected child maltreatment. First, there must be appropriate communication with the family about the child’s condition and the physician’s concerns. The physician must communicate clearly that there are questions about how the child got hurt and worry that the child may have been abused. The family should be informed that the physician is a mandated reporter who must notify the state’s child protection agency about “suspected” maltreatment and not just cases of confirmed abuse. The second step is appropriate medical care for the child; third is ensuring the child’s safety. Although some abused and neglected children are admitted to the hospital for protection and further evaluation, it is not uncommon for children who are not seriously injured to be placed in foster care or with relatives by the child protection agency. Fourth, the physician must assess the child’s medical, developmental, emotional, and educational needs so that appropriate services can be provided. Fifth, the parents’ and family’s needs also must be evaluated so that adequate parenting can be ensured. And sixth, siblings should be assessed carefully to determine whether they have been maltreated.

These steps, which usually are carried out over time by professionals from several disciplines, including primary care clinicians, pediatric experts in child abuse, child protective services workers, police, and mental health clinicians, help determine the kinds of interventions needed. Services for the child might include ensuring appropriate medical care, participation in an early intervention program or a crisis nursery, or mental health counseling for an older child. For families, services might include concrete assistance (eg, ensuring adequate housing or transportation for the child’s medical care), treatment programs for the parents’ own problems (eg, drug treatment, mental health counseling, or counseling for domestic violence), or treatment programs that focus on parenting (eg, parent-child programs).

If the suspected maltreatment is substantiated, child protective services can help the family obtain the necessary services and monitor the child’s safety. Unfortunately, most state protective service agencies are understaffed because of budgetary constraints and often have difficulty providing the necessary supervision of families whom they are mandated to serve. Pediatricians can help monitor families by providing follow-up care that focuses on the child’s needs. This includes re-reporting the child to protective services if new injuries occur or if the child continues to be at substantial risk of maltreatment.

Maltreated children whose safety cannot be ensured in the home usually are placed in foster care or with relatives.

Maltreatment can have long-lasting and devastating effects on the development of children, adolescents, and adults. Although a child can be physically harmed from maltreatment, and brain injuries can have serious, long-term consequences, it is likely that the major consequences of maltreatment are related to its emotional impact. Also, recent studies have shown that childhood stressors such as physical and sexual abuse can affect brain development and disrupt the hypothalamic-pituitary-adrenal axis.67 In addition, studies have documented that the long-term effects of abuse can be determined by an interaction between genetic predisposition (or protection) and an abused child’s environment.68 Many other factors also can affect the development of a maltreated child, such as malnutrition, placement in multiple foster homes, or exposure to family violence. Thus, the link between child maltreatment and subsequent outcomes is not straightforward.

Studies of abused and neglected children indicate that they have a higher rate of delayed intellectual development, poor school performance, aggressive behaviors, and social and relationship deficits compared to nonmaltreated children.63 There also is an increased occurrence of emotional difficulties, including depression, suicide attempts, and self-mutilation. Children who were maltreated are likely to have difficulty in forming trusting relationships with adults and in viewing adults as helpful people in their lives. Children who were neglected may be indiscriminate in seeking adult relationships.

There is clear evidence that children who have been maltreated have substantial problems with social interactions with peers. Children who were physically abused, in particular, have been noted to be physically aggressive and antisocial. Both abused and neglected children are at an increased risk of juvenile delinquency, substance abuse, and self-destructive behaviors during adolescence.69

Adults who were abused or neglected as children often have difficulty forming intimate relationships and often choose partners with similar problems. Parents who were abused as children are at increased risk of abusing their own children (intergenerational transmission of abuse), but the link between experiencing childhood abuse and abusing one’s own child is not a simple linear association. Although some investigators have estimated that 30% of abused parents will abuse their own children, further research is needed to define this risk more clearly.70 Adult survivors of childhood abuse suffer at significantly higher rates than others from depression, anxiety disorders, eating disorders, posttraumatic stress disorder, and chronic pain syndromes. Furthermore, adults maltreated as children are more likely than nonabused adults to be obese or physically inactive; to engage in smoking, substance use, and unsafe sex; to attempt suicide; and to have an unintended pregnancy.71,72

Sexual abuse also has a major adverse impact on development. Children who have been victims of sexual abuse may develop low self-esteem and feelings of guilt and shame and may learn to use sexual behaviors inappropriately in their interactions with peers and adults. Teenage girls and adult women are at increased risk of promiscuity, have difficulties forming intimate relationships, and may be revictimized. They also are at increased risk of having mental health problems, such as depression, suicide, eating disorders, multiple personality disorder, and posttraumatic stress disorder.73 Males who were sexually abused as children are at increased risk of having mental health problems, abusing substances, or becoming perpetrators.8

Little data exist about the long-term effects of specific treatments of maltreated children. The expectation is that early recognition and appropriate treatment for the child and family will minimize adverse outcomes. The presence of a supportive adult who is able to respond to the emotional needs of the child seems to minimize the short-term psychological effects of maltreatment, but less is known about its importance regarding long-term sequelae.