In 1996, 4.3 percent of children younger than 18 years in the United States were reported to be victims of maltreatment.¹ More than 3 million cases of child abuse are reported each year, with 1 million cases later being substantiated.² More than 1,400 children die from inflicted injuries annually,³ 45 percent of whom are younger than 12 months.⁴ Child abuse is one of the leading causes of injury-related mortality in infants and children. An abused child has approximately a 50 percent chance of being abused again, and has an increased risk of dying if the abuse is not caught and stopped after the first presentation.^5,6 The responsibility, therefore, lies with physicians to recognize and treat these cases at first presentation to prevent significant morbidity and mortality.

Definition

The Child Abuse Prevention and Treatment Act (CAPTA) defines abuse as a recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of serious harm; involves a child; and is carried out by a parent or caregiver who is responsible for the child's welfare.² CAPTA also includes neglect within the definition; however, each state is responsible for defining child abuse and maltreatment within its own civil and criminal codes.

Risk factors for abuse can be categorized as caregiver, child, and family or environmental factors (Table 1^6–14 ). Notably, intimate partner violence in the home is associated with child maltreatment (odds ratio: 3.0).¹³

There are four main types of child abuse: neglect and emotional, physical, and sexual abuse. Medically, each is approached differently, but all require that the physician report suspicions to appropriate authorities and involve other members of the health care community.

Neglect

Neglect is the most common (60 percent of cases) form of reported abuse^4,7,15–17 and is the most common cause of death in abused children.^18,19 It is defined by the Office on Child Abuse and Neglect as failure to provide for a child's basic physical, emotional, educational/cognitive, or medical needs.⁷ The four subtypes of neglect are physical, emotional, educational, and medical.

Physical neglect involves the failure to provide adequate food, clothing, shelter, hygiene, protection, or supervision. Emotional neglect is the failure to provide love, security, affection, emotional support, or psychological care when needed. Exposure to intimate partner violence also may be considered a type of neglect. Educational or cognitive neglect involves the lack of proper enrollment in school, lack of supervision of school attendance, or failure to meet essential educational needs. Medical neglect is the delay in or refusal to seek medical care, resulting in damage to the child's well-being.

Although there is insufficient evidence to recommend a parent education and support program to prevent child maltreatment, home visitation programs have been shown to be effective in reducing abuse in high-risk families.^1,20 Physicians can provide anticipatory guidance and education for parents and care providers. Well-child visits should include information about nutrition, safety, injury prevention, developmental staging, dental and eye care, and educational needs. Resources for physicians and parents are summarized in Table 2.

If neglect is suspected, the physician should obtain a full medical history (e.g., prenatal and postnatal care, diet, immunizations, major illnesses, growth curve, developmental milestones, hospitalizations, previous physician visits); psychosocial history (e.g., family composition, intimate partner violence, job status, use of drugs and alcohol in the home, past involvement with Child Protective Services); and a complete physical examination. If a diagnosis of neglect is unclear, proper management includes arranging a home visit by a physician, social worker, or home nurse; scheduling frequent medical follow-up; and obtaining a social work consultation. If the caregiver refuses to cooperate with these interventions, or if the child fails to improve appropriately with intervention, then Child Protective Services should be contacted.¹⁷

Emotional Abuse

Emotional abuse may be the most difficult form of abuse to recognize in clinical practice.^14,21,22 It develops as a result of repeated damaging interactions. The Office on Child Abuse and Neglect defines emotional abuse as abuse that results in demonstrable harm (e.g., impaired psychological growth and development) of a child.¹⁴ There are several subtypes of emotional abuse including rejection, isolation, terrorism, ignorance, psychological unavailability, corruption, and inappropriate expectations of or demands on the child.^14,22,23

Patterns of behavior that should raise concern about the possibility of emotional abuse include social withdrawal, excessive anger or aggression, eating disorders, failure to thrive, developmental delay, and emotional disturbances (e.g., depression, anxiety, fearfulness, history of running away from home). Physicians should express their concerns to the child and family and try to determine the severity of the problem.

Mental health consultation should be considered for families of children who have been emotionally abused. Although there is insufficient evidence to suggest that parent education and psychotherapy prevent child maltreatment, these interventions may be recommended for other reasons.¹ If the episode of suspected emotional abuse is isolated, and there is no immediate danger to the child, physicians should recommend family therapy, parental training, and other supportive therapy for the child and family. If emotional abuse is recurrent or there is a possibility of imminent harm, Child Protective Services should be contacted and removal of the child from the home considered.²¹

In some areas, exposure to intimate partner violence in the home is considered by statute to be a source of emotional harm. Physicians should seek advice of local experts to determine if children who witness intimate partner violence should be referred to Child Protective Services.²⁴ Screening for intimate partner violence, however, has not been shown to decrease disability or risk of premature death.²⁵

Physical Abuse

CLINICAL EVALUATION

Physical abuse should be part of the differential diagnosis for all injuries in children.²⁶ The physician must determine if the lesions present could be inflicted or noninflicted. Clues to assist in this determination involve a series of questions about each injury (Table 3^26–28 ).

Certain elements of the history or presentation should alert the physician to the possibility of abuse: for example, if the history provided by the caregiver does not explain the child's injuries, the history changes over time, the history of self-inflicted trauma does not correlate with development, or if there is an inappropriate delay in seeking care.

The diagnosis of abuse should be pursued if there are injuries to multiple areas, injuries in various stages of healing, or suspicious injury patterns. Bruises, bites, burns, fractures, abdominal trauma, and head trauma are the most common physical findings. Injuries considered suspicious for inflicted injury include posterior rib fractures; retinal hemorrhages; metaphyseal or complex skull fractures in infants; long bone fractures in children younger than two years; scapular, spinous process, and sternal fractures; and cigarette burns.²⁸ Subdural hemorrhages in infants are highly suggestive of inflicted trauma.²⁹ The American Academy of Orthopaedic Surgeons states that there is no pathognomonic fracture pattern in abuse.²⁸ Transverse fractures are the most common type of fracture, regardless of etiology, and femoral spiral fractures are no more common in inflicted injuries than in noninflicted ones.³⁰

Evaluation of physical abuse in children can be time consuming but is vitally important. Histories from caregivers should be obtained separately and as soon as possible; careful documentation is essential. Prepared examination packets that include adequate space for historical data and a physical examination section with drawings to facilitate proper documentation of all injuries are helpful. The state of California has sample forms (Office of Emergency Services [OES] 900 forms) available at http://www.oes.ca.gov/Operational/OESHome.nsf/CJPD_Documents?OpenForm.³¹

Photographs of injuries should be taken. There are guidelines available to help family physicians better document injuries (Table 4).^32,33 When possible, a medical photographer or child abuse investigative authority should retake the photographs.

DIAGNOSTIC TESTING

Because organic and medical causes should be considered in the differential diagnosis of suspected physical abuse (Table 5^13,34 ), ancillary studies that assist in a full medical evaluation should be performed (Table 6^27,28,35 ). The American Academy of Pediatrics and the American College of Radiology consider a skeletal survey the method of choice for skeletal imaging in suspected child physical abuse cases; therefore a skeletal survey is mandatory for all children younger than three years with suspicious trauma.^27,36

MANAGEMENT

Once physical abuse of a child is suspected, the physician is required by law to report it to authorities.³⁵ Medical management can range from inpatient care to outpatient treatment with close follow-up by a physician, a social worker, and Child Protective Services. Inpatient care helps address medical needs; facilitates studies, observation, and evaluation; and protects the child from further harm. Criteria for considering admission includes medical indications (e.g., severe burns, head injury, requirement for serial examinations), unsafe home environment, delayed outpatient Child Protective Services evaluation, and inpatient observation of child-parent interactions.³⁷

If the parent or guardian is suspected of being a perpetrator, then inpatient evaluation is appropriate. A multidisciplinary approach, or “child protection team,” is strongly encouraged to ensure adequate evaluation, treatment, and follow-up of a potentially abused child.⁷ Recommended members for a multidisciplinary team include the admitting or evaluating physician, a children's physician or children's forensic specialist, Child Protective Services, social work services, nursing staff, mental health professionals, and law enforcement.

Sexual Abuse

LEGAL DEFINITION

Child sexual abuse is defined clinically and legally. Legally, there are child protection and criminal statutes. Federal child protection statutes consider sexual abuse and exploitation as a subcategory of child abuse. CAPTA defines sexual abuse as:

The federal statute does not provide an age limit for definition purposes; it indicates that age limits in state law apply.³⁷ Specific state statutes can be located at http://www.childwelfare.gov/systemwide/laws_policies/search/index.cfm.

CLINICAL EVALUATION

Less than 10 percent of substantiated child sexual abuse cases have physical findings on examination^38–41; therefore, the history is the most important part of the sexual abuse evaluation. Documentation should include the child's exact words. A suggested approach to obtaining a history from a potential victim is shown in Table 7.⁴² Physicians who plan to interview or evaluate suspected victims should consider special training.

Timing of the physical examination depends on the last reported incident of sexual contact or if symptoms are currently present. An examination should be done promptly if a child with suspected maltreatment complains of dysuria, anal or vaginal bleeding, vaginal discharge, or pain with defecation. Also, a thorough physical examination should be performed at the time of initial interview if the reported incident occurred less than 72 hours before and the patient has a history highly suggestive of abuse. For these instances, sexual assault kits (i.e., rape kits) usually are available in emergency departments or child abuse centers. Examinations should be done by health care professionals familiar with forensic examinations (e.g., experienced primary care physicians, emergency department personnel, or sexual assault nurse examiners).²⁷

Examination under anesthesia should be considered for acutely assaulted prepubertal girls with persistent vaginal or rectal bleeding or severe abdominal pain.^43,44 Examination supplies must include culture medium for gonorrhea and chlamydia rather than DNA probes or antibody staining because the standard of care for children is culture analysis. Colposcopy is now recommended for adequate sexual assault evaluation because it facilitates evaluation and documentation with digital imaging. A speculum is not used in a prepubescent child because the genitalia can be visualized adequately with proper technique and positioning.

If the last known incident of sexual contact occurred more than 72 hours before presentation, the child can be scheduled for an examination at a child advocacy center or other center specializing in sexual assault examinations. Child advocacy centers are members of the National Children's Alliance (http://www.nca-online.org). Membership requires a child-appropriate facility, multi-disciplinary case review team, provisions for medical and mental health examinations and treatment, and a system for tracking cases.³⁴

Much of the approach and management of child abuse is directed by expert opinion or legal mandate. Physicians must use every available piece of clinical evidence to effectively diagnose and manage child abuse. Physicians should seek preventive measures through support of home visitation but recognize that routine screening for abuse has not been shown to be beneficial.^1,25