Child maltreatment

Child maltreatment is any act or failure to act that results in potential or actual harm to a child, usually involving a caregiver. Types of child maltreatment include neglect, physical abuse, sexual abuse, psychological maltreatment, and medical child abuse. Children under the age of 1 year are most commonly affected. Risk factors for child maltreatment include physical or developmental disabilities and caregiver factors (e.g., substance use disorders, intimate partner violence). When child maltreatment is suspected, use a trauma-informed approach to perform a detailed clinical evaluation, including evaluation of acute injuries, medical and developmental history, growth assessment, and a physical examination, ensuring detailed documentation. Management includes medical stabilization if necessary and immediately reporting any suspected child maltreatment to Child Protective Services (CPS). Additional diagnostic testing and management should be performed based on the type of abuse suspected (e.g., imaging for patients with suspected fractures, STI testing for suspected sexual abuse). Prevention includes the identification and management of risk factors for child maltreatment.

Definition ^[1][2]

• Any act or failure to act that results in potential or actual harm to a child, usually involving a caregiver
• Types of child maltreatment include: ^[2]
  • Child neglect
  • Physical child abuse
  • Child sexual abuse
  • Psychological maltreatment of a child
  • Medical child abuse
• Exact legal definitions of child maltreatment vary by state; check local laws.

Epidemiology ^[1]

• Approx. 7 per 1000 children in the US experience child maltreatment annually.
• The highest rate of child maltreatment and death is in children < 1 year of age. ^[1]
• The perpetrator is usually a caregiver (a parent is involved > 80% of the time).
• Affects children of all races and socioeconomic groups, but appears to be: ^[3][4]
  • Overreported in Black, Latino, and multiracial families and households with low socioeconomic status
  • Underreported in White and affluent families

Risk factors for child maltreatment ^[2][5]

Child factors

• Physical or developmental disabilities
• Behavioral issues
• Chronic medical conditions
• Preterm birth
• Unintentional or unwanted pregnancy

Caregiver and family factors

• Intimate partner violence
• Personal history of abuse during childhood
• Unemployment, financial hardship
• Low level of education
• Substance use disorders and/or mental health issues (e.g., depression)
• Limited understanding of parenting (e.g., of normal childhood behavior and development)
• Young and/or single parents
• Social isolation
• Other individuals residing in the home (e.g., partner of the parent or caregiver, foster siblings, extended family members) ^[1]

Approach to suspected child maltreatment

• Always use a trauma-informed approach in suspected cases of child maltreatment.
• Interview the child and parent/caregiver separately, if possible. ^[5]
• Elements of the assessment may be used as legal evidence. ^[2]
  • Ensure detailed documentation.
  • Swabs, clothing, and other items may contain biological evidence (e.g., blood, semen).
• Tailor assessment to the type of suspected abuse, but be aware that more than one type may have occurred.

Involve a multidisciplinary child abuse team and/or medical forensic specialists when available. ^[2][5]

Clinical evaluation ^[2][6]

• History from the caregiver
  • Medical and surgical history, including:
    • Prenatal and birth history ^[5]
    • Pediatric developmental history
    • Developmental milestones
  • Family history of genetic, metabolic, and bone diseases
  • Social history for risk factors for child maltreatment
  • Acute injuries: Ask about the nature, mechanism, and timing of injury.
• History from the child
  • Conduct the interview without the caregiver present, if possible.
  • Ask the child about their concerns and what occurred using age-appropriate, open-ended questions.
  • Focus on information necessary for the diagnosis and treatment of medical conditions.
  • Assess for potential mental health complications of abuse, including:
    • Acute and posttraumatic stress disorders
    • Signs of depression (see “Depression in children”)
• Physical examination ^[2]
  • Ensure a chaperone is present.
  • Examine all systems, including complete skin examination for injuries (e.g., bruising).
  • Assess growth (see also “Clinical features of growth faltering”).
  • For acute injuries, see also:
    • “Pediatric fractures”
    • “Approach to burns”
  • If child sexual abuse is suspected, see “Physical examination for child sexual abuse.”

Validated tools, e.g., modified versions of the HITS screen for children (PedHITSS) and teenagers (TeenHITSS), can help detect child maltreatment. ^[2][7]

Red flags for child maltreatment ^[5]

• History does not fit clinical findings or patterns of behavior for the child's age
• Changing history of an injury or illness
• Delay in seeking medical treatment
• Features of child neglect
• Injuries concerning for nonaccidental trauma
• Red flags for child sexual abuse
• Red flags for human trafficking
• Red flags for medical child abuse

Management ^[2][8]

• Notify CPS for all suspected cases of child maltreatment; , and if there is an immediate concern for safety, law enforcement.
• Admit to hospital if medical stabilization is required.
• Assess the safety of other individuals in the household.
  • Determine if there are other children in the home; assess as needed. ^[3]
  • Consider caregiver screening for intimate partner violence. ^[9]
• Tailor assessment to the suspected type of abuse (see the relevant sections for further information).
  • Physical child abuse
    • Perform dedicated imaging of any suspected injury site and, if appropriate, a skeletal survey.
    • Consider a coagulation panel and CBC to assess for coagulopathy. ^[10]
  • Child sexual abuse: Offer STI screening and emergency contraception as needed.
  • Suspected poisoning (accidental or intentional) : Consider toxicology screening. ^[3]
• Consult with specialists as needed, e.g.:
  • Child abuse pediatricians
  • Ophthalmology
  • Radiology
  • Orthopedics
  • Mental health providers

Physicians are required by law to report concerns if there are red flags for child maltreatment. ^[8]

Child neglect is the failure to meet a child's basic physical, emotional, medical, or educational needs. ^[2]

Types of child neglect ^[2]

• Failure to provide appropriate food, clothing, or shelter
• Poor supervision and protection from potential harm
• Denying emotional support and social interaction
• Avoiding medical care when required
• Failure to meet educational needs

Child neglect is the most common form of child maltreatment. ^[2]

Clinical features of child neglect ^[2][11][12]

• Growth faltering
• Abnormal language, social, and/or emotional development
• Abnormal attachment (e.g., reactive attachment disorder)
• Frequent hunger
• Inadequate, inappropriate, or soiled clothing
• Poor personal hygiene
• Dental problems
• Social issues with peers or adults (e.g., disinhibited social engagement disorder)
• Behavioral concerns (e.g., impulse and conduct disorders)
• Clinical features of ADHD
• Substance use

Management ^[2]

• Inquire about contributing factors, e.g.:
  • Poverty
  • Insecure housing
  • Food insecurity
  • Barriers to accessing health care
• Provide education on safe care (see “Anticipatory guidance for children”) and refer to community resources.
• Refer to CPS for persistent neglect despite referrals for assistance.
• See also “Approach to suspected child maltreatment.”

Prognosis

Child neglect can have long-term intellectual, social, and mental health consequences and can result in death. ^[2]

Psychological maltreatment of a child is defined as recurrent actions and behaviors from parents or caregivers that have a negative impact on the cognitive, social, emotional, and physical development of a child. ^[13]

Types of psychological maltreatment ^[13]

• Spurning (e.g., name-calling, insulting)
• Terrorizing (e.g., intimidation, threats of violence)
• Isolating from peers and adults
• Exploiting and/or corrupting (e.g., allowing the child to witness abuse being inflicted on another)
• Emotional detachment
• Neglect for reasons other than inadequate resources

Clinical features ^[13]

• Attachment issues (e.g., reactive attachment disorder)
• Disruptive behaviors in childhood (e.g., aggression toward other children or animals, atypical tantrums)
• Developmental delay
• Issues with academic performance
• Impaired social skills
• Depressed or anxious mood
• Psychosocial short stature or growth faltering

Management

• See “Approach to suspected child maltreatment.”
• Additional management for psychological maltreatment includes:
  • Close monitoring of behavioral and physical development over time
  • Providing or referring to services based on the nature and consequences of abuse.

Prognosis

Psychological maltreatment is associated with mental health and substance use disorders in adulthood ^[14]

Overview ^[2][5][8]

• Physical abuse is any nonaccidental injury to a child.
• Most common in young children, particularly in the first year of life ^[3][15]
• Consider physical abuse with injuries involving any of the following:
  • Patterns suspicious for nonaccidental injuries in children
  • Multiple organ systems
  • Sites that do not overlie bones
  • Accompanying red flags for child maltreatment

Maintain a high index of suspicion for physical child abuse in young children; up to 20% of nonaccidental fractures are misattributed to other causes in children < 3 years of age. ^[8]

Suspicious bruises (TEN4): Torso, Ear, Neck, any bruise in these locations in children ≤ 4 years of age and any bruise (regardless of location) in infants < 4 months of age

Management of physical child abuse ^[2][8]

• See “Approach to suspected child maltreatment.”
• Additional workup for suspected physical child abuse includes:
  • Documenting injury characteristics in detail (e.g., location, size, shape, color, nature)
  • Detailed imaging of any suspected injury sites
  • Skeletal survey in younger and nonverbal children
  • Consideration of coagulation panel and CBC for undiagnosed coagulopathy in children with isolated: ^[10]
    • Bruising
    • Intracranial hemorrhage

Other children in the household of victims of physical abuse should also be evaluated for evidence of abuse. ^[8]

Skeletal survey ^[8][15]

• Indications ^[15]
  • All children ≤ 24 months of age with suspected physical abuse
  • Assessment of children > 24 months of age with: ^[3][8][15]
    • Unexplained head or abdominal injury or fracture patterns suspicious for nonaccidental injury in children
    • Difficulties communicating (e.g., developmental delay)
• Components: X-ray images of all of the following areas. ^[15]
  • Skull
  • Chest, including oblique views of the ribs
  • Cervical, thoracic, and lumbosacral spine
  • Pelvis
  • Upper and lower extremities (including long bones, hands, and feet)

Repeat a focused skeletal survey in 2 weeks in patients ≤ 24 months of age with abnormal or equivocal findings on initial imaging and/or in whom clinical suspicion of physical abuse remains. ^[8][15]

General principles

• Abusive head trauma is a characteristic pattern of intracranial trauma seen in severe physical child abuse (e.g., violent shaking leading to shaken baby syndrome). ^[19]
• Most common cause of death from head injury in children < 2 years of age ^[19]
• Pathophysiology includes: ^[20]
  • Rotational and shearing forces → shearing off of bridging veins → subdural hematoma
  • Shaking of a child with weak neck support → respiratory problems and apnea → hypoxia → brain edema and ischemia → diffuse axonal damage

Clinical features ^[19][21][22]

• Irritability or lethargy
• Seizures
• Vomiting
• Inconsistent or implausible history from caregiver
• On examination: external injuries may not be visible
  • Retinal hemorrhages
  • Tense fontanelle ^[23]
  • Macrocephaly ^[22]
  • Other injuries suggestive of physical child abuse

External injuries may be hardly evident or absent in abusive head trauma. ^[19]

Diagnostics ^[15]

• Initial imaging: usually CT head without contrast
  • Performed in the emergency setting for suspected acute bleeding and bony evaluation
  • Findings include: ^[22]
    • Subdural hematomas and/or subarachnoid hemorrhage of varying ages
    • Reversal sign: diffuse blurring of the gray-white matter interface coupled with increased density of the thalamus and cerebellum ^[23][24]
    • Diffuse punctate hemorrhages ^[25]
    • Skull fracture
• Additional imaging
  • MRI brain is often performed following abnormal findings on CT head to evaluate for: ^[15]
    • Small volume extra-axial hemorrhage
    • Developing parenchymal injuries
  • MRI spine: for assessing spinal injuries ^[15]
  • Skeletal survey: indicated for all children < 2 years of age with abusive head trauma ^[26]
• Fundoscopy: performed by an ophthalmologist
  • Assess within 24–36 hours of injury. ^[22]
  • For signs, see “Findings in retinal hemorrhage.”

Differential diagnoses

See “Mimics of physical child abuse.”

Management

• Initial management of TBI to stabilize the patient
• See “Management of physical child abuse.”

Complications

• Death
• Neurological deficits (e.g., sight, hearing, and speech impairment)
• Posttraumatic epilepsy
• Developmental delay

Abusive head trauma is fatal in up to 20% of children. ^[22]

Definitions

• Child sexual abuse: involvement of a child in sexual activity with an adult or other child that involves any of the following ^[27]
  • Lack of proper understanding and inability to provide informed consent
  • Lack of developmental readiness and/or inability to provide consent
  • Is illegal or socially unacceptable
• Child sex trafficking: a form of human trafficking involving any role in a child's participation in sexual activity for commercial purposes (e.g., recruitment, harboring, transporting) ^[1]

Epidemiology

• The perpetrator is usually an adult who is known to the child. ^[28]
• Estimated lifetime incidence: 5–25% ^[6]

Types of child sexual abuse

• Sexual intercourse (oral, anal, or vaginal penetration)
• Molestation (genital contact without penetration)
• Exposure to a perpetrator's genitalia
• Forced sexual interaction with another child or object
• Exposure to explicit material

Clinical features of child sexual abuse ^[6]

• Behavior or sexual insights that are age-inappropriate ^[29]
• Injuries in the genital, anal, and oral areas ^[30]
• Recurrent urinary tract infections
• Signs and symptoms of STIs
• Pregnancy
• Often no visible signs on physical examination
• See also “Red flags for human trafficking” and “Red flags for sexual assault.”

Differential diagnoses

See also “Vulvovaginitis in children.” ^[31]

Even in the absence of physical signs, sexual abuse should always be considered in young children presenting with behavioral changes or signs of sexually transmitted infections.

Management of suspected child sexual abuse ^[6][27]

Approach ^[6][30]

• See “Approach to suspected child maltreatment” for the basic principles of initiating an assessment.
• Refer directly to a specialized child sexual abuse service, if available. ^[6]
• If not available, as indicated:
  • Perform STI testing.
  • Initiate HIV postexposure prophylaxis.
  • Give HPV and hepatitis B vaccinations.
  • For postpubertal individuals, offer:
    • Emergency contraception
    • Pregnancy testing
    • Prophylaxis for bacterial STIs (see “Postassault STI prophylaxis”). ^[30]
  • Refer for a sexual assault forensic examination. ^[32]
• Arrange appropriate follow-up.
  • Consider repeat physical examination and STI testing in 2–6 weeks for patients with recent sexual contact.
  • Repeat serological testing in 6–12 weeks if HIV, HBV, or syphilis is suspected and initial testing is negative.
  • Refer to specialists (e.g., child abuse pediatrician, mental health providers) as indicated.

Collection of forensic evidence is recommended within 72 hours of abuse involving bodily fluids. ^[6]

Physical examination for child sexual abuse ^[6]

• Ensure a chaperone is present (e.g., caregiver or other medical professional).
• Outline the examination steps before starting.
• Examine the child fully for other signs of child maltreatment.
• Include an anogenital examination; instrumentation is not necessary in most cases.

Refer children with abnormalities on anogenital examination for specialist evaluation (e.g., child abuse pediatrician). ^[6]

Do not perform a speculum examination in a prepubertal child. Refer patients with suspected internal genital trauma for examination under anesthesia. ^[6]

STI testing ^[30]

• Indications
  • All adolescents evaluated for sexual abuse
  • Younger children evaluated for abuse with certain factors, e.g.:
    • Anogenital or oropharyngeal penetration
    • Perpetrator is unknown
    • Perpetrator is known to have an STI or is at high risk for STIs
    • Household member with an STI
    • High community STI rates
    • Clinical features of STI or diagnosis of one STI
    • Patient or family request
    • Inability to communicate details of the abuse
• Methods: Perform STI testing before initiating treatment to improve the accuracy of results. ^[30]
  • All patients: gonorrhea testing and chlamydia testing
  • Vesicles or ulcers in the anogenital area: diagnostics for HSV
  • Serologic testing for the following, if suspected:
    • Syphilis
    • HIV
    • Hepatitis B
  • Girls only:
    • Wet mount and culture for trichomoniasis
    • Wet mount for bacterial vaginosis, if there is vaginal discharge

Presumptive treatment for bacterial STIs is not usually recommended for prepubertal children as the incidence of STIs after abuse is low, ascending infection is rare, and follow-up is more likely to take place than with adolescents or adults. ^[30]

Beyond the newborn period, diagnosis of an STI in children is highly suspicious for sexual abuse. ^[30]

Individuals who perpetrate medical child abuse usually have factitious disorder by proxy; this is covered separately in “Somatic symptom and related disorders.”

Definition

• Medical child abuse is a form of child maltreatment in which a caregiver fabricates and/or induces symptoms in a child, resulting in unwarranted and potentially harmful medical care. ^[33][34]
• Symptoms may be:
  • Induced by administering inappropriate drug therapy or other agents ^[33]
  • Fabricated or exaggerated by contaminating samples (e.g., urine specimens) ^[33]

Clinical features ^[33]

• Signs and symptoms of induced illness, e.g.:
  • Bleeding
  • Neurological symptoms (e.g., seizures, CNS depression)
  • Rashes
  • Gastrointestinal symptoms (e.g., diarrhea, vomiting)
  • Apnea
  • Symptoms of urinary tract infection, hematuria
  • Signs of infection (e.g., fever)
• Consequences of induced or fabricated illness, e.g.:
  • Complications from procedures
  • Mental health conditions

Red flags for medical child abuse ^[33]

• Medical history is inconsistent and/or history is incongruent with examination findings.
• Clinical findings that are unusual and occur in the presence of a single caregiver
• Reported history of unusual illnesses or deaths in other family members
• The caregiver is not relieved in response to reassurance that the child is healthy.
• Persistent requests for invasive diagnostics or treatments
• Conspicuously inadequate response to treatment for a particular condition
• Reported sensitivity to several substances or medications

Children with induced or fabricated illness often have a history of multisystem involvement and receive care from several specialists. ^[33]

Management ^[33]

• See “Approach to suspected child maltreatment.”
• Additional management in suspected medical abuse includes:
  • Exclusion of medical causes of the symptoms ^[33]
  • Referral of patients for a multidisciplinary evaluation, including CPS, mental health professionals, and child abuse specialists.
• See “Factitious disorder imposed on another” for details on DSM-5 diagnostic criteria and management of the perpetrator.

Victims of child medical abuse may be convinced by their perpetrator that they have a nonexistent illness. ^[33]

• Educate all parents on the safe care of children (see “Anticipatory guidance for children”).
• Identify protective and risk factors for child maltreatment (e.g., through pediatric mental and social health screening).
• For patients with risk factors, offer interventions for the patient and/or family as indicated, e.g.: ^[28][35]
  • Addressing social determinants of health
  • Referring caregivers to psychosocial support services
  • Referral for home visitation programs, where available
  • Parenting programs focused on behavior and discipline
• Provide information on normal child development including age-appropriate behaviors to manage parent expectations.
• Discuss age-appropriate discipline as well as anger and conflict management techniques.