Child abuse: what it is, how to recognise it and how to intervene. Overview of child maltreatment
Child abuse: child maltreatment is inappropriate behaviour towards a child and involves a substantial risk of causing physical or emotional harm. In general, four types of maltreatment are recognised: physical abuse, sexual abuse, emotional abuse (psychological abuse), and neglect
The causes of child maltreatment are varied and not fully understood.
Abuse and neglect are often associated with physical injuries, growth and developmental delays, and mental problems
Diagnosis is based on history, physical examination, and sometimes laboratory tests and imaging.
Management includes documentation and treatment of any trauma and urgent physical and mental conditions, mandatory reporting to the appropriate state agency, and sometimes hospitalization and/or foster care to keep the child safe.
In 2018, 4.3 million reports of suspected child maltreatment were filed with Child Protective Services in the United States involving 7.8 million children.
Approximately 2.4 million of these reports were reviewed in detail and approximately 678 000 maltreated children were identified.
Both sexes are equally affected overall, but boys are more frequently physically abused.
The younger the child, the higher the rate of victimisation.
Approximately three-fifths of all reports to Child Protective Services were made by professionals who had an obligation to report maltreatment (e.g., educators, law enforcement, social service personnel, law enforcement professionals, health care providers, medical or mental health personnel, foster carers).
Of the cases reviewed in the United States in 2018, 60.8% involved only neglect (including medical neglect), 10.7% involved only physical abuse, and 7% involved only sexual abuse.
Many children (15.5%) were victims of multiple types of maltreatment.
In 2018, about 1770 children died from maltreatment in the United States, about half of whom were < 1 year old.
About 80% of these children were victims of neglect and 46% were victims of physical abuse with or without other forms of maltreatment.
About 80% of perpetrators were parents acting alone or with other individuals (1).
Potential perpetrators are defined slightly differently in different states of the United States, but in general, to be considered abuse, the actions must be performed by a person responsible for the child’s welfare.
Thus, perpetrators can be parents and other relatives, people living in the child’s home who have occasional responsibilities, teachers, bus drivers, counsellors, and so on.
Unrelated persons who commit violence against children with whom they have no connection or responsibility (e.g. as in school shootings) are guilty of assault, murder and so on, but do not commit child abuse.
US Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau: Child maltreatment 2018 (2020). Available from the Children’s Bureau website.
Child abuse, classification of child maltreatment
Different forms of maltreatment often co-exist and there is considerable overlap.
The 4 main forms include
- Physical abuse
- Sexual abuse
- Emotional abuse
Intentionally feigning, faking or exaggerating medical symptoms in a child that result in potentially harmful medical interventions is considered a form of abuse (abuse in a medical setting).
Physical abuse involves caregivers and consists of inflicting physical harm or engaging in actions that create a high risk of trauma.
Assault by someone who is not a caregiver or in a position of responsibility for the child (e.g., a shooter in a school mass shooting) is not specifically child abuse.
Specific forms include shaking, falling, hitting, puncturing, and burning (e.g., by heat or cigarettes). Maltreatment is the most frequent cause of severe brain injury in infants.
In children learning to walk, abdominal trauma is also common.
Infants and toddlers learning to walk are the most vulnerable, as the developmental stages they undergo (e.g. colic, inconsistent sleep patterns, anger, hygiene training) can induce frustration in caregivers.
This age group also has an increased risk as they cannot report their abuse. The risk decreases in the first years of school.
Any action towards a child that is carried out for the sexual gratification of an adult or significantly older child constitutes sexual abuse (Paedophilic Disorder).
Forms of sexual abuse include intercourse, i.e., oral, anal, or vaginal penetration; molestation, i.e., genital contact in the absence of full intercourse; and forms that do not involve physical contact with the aggressor, such as exposure of the genitals by the aggressor, showing sexual material to a child, and forcing a child to participate in a sexual act with another child or to participate in the recording of pornographic material.
Sexual violence does not include sexual play, in which children of similar ages look at or touch each other’s genital areas without violence or coercion.
Guidelines differentiating sexual abuse from play vary from state to state, but in general sexual contact between individuals with an age difference > 4 years (chronologically or in mental or physical development) is considered inappropriate.
Emotional abuse is the infliction of emotional trauma through the use of words or actions.
Specific forms include berating a child by shouting or screaming, belittling a child’s abilities and achievements, intimidating and terrorizing a child with threats, and exploiting or corrupting a child by encouraging deviant or criminal behaviour.
Emotional abuse also occurs when words or attention are withheld or denied, becoming essentially emotional neglect (e.g., ignoring or rejecting a child or isolating a child from possible interactions with other children or adults).
Medical child abuse (in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] formerly Munchausen syndrome by proxy, currently defined as a fictitious disorder imposed on another) occurs when caregivers intentionally produce or falsify physical or psychological symptoms or signs in a child.
The caregiver may harm the child with drugs or other substances or add blood and bacterial contaminants to urine samples in order to simulate an illness.
Victims of this type of child abuse receive unnecessary and harmful or potentially harmful evaluations, examinations, and/or treatment.
Neglect is the failure to address or meet a child’s basic physical, emotional, educational and medical needs. Neglect differs from abuse because it usually occurs without malicious intent.
Different types of neglect can be defined as
- Physical neglect includes failure to provide adequate levels of nutrition, clothing, shelter, supervision and protection from potential harm.
- Affective neglect is the failure to provide affection or love or other emotional support.
- Educational neglect is the failure to enrol a child in school, ensure school attendance, or provide education at home.
- Health neglect is the failure to provide a child with the appropriate care or treatment needed for physical or mental trauma or disorders.
However, failure to provide preventive care (e.g. vaccinations, routine dental examinations) is not usually considered neglect.
Severe corporal punishment (e.g., whipping, burning, scalding) clearly constitutes physical abuse, but for lesser degrees of physical and emotional punishment, the boundary between socially accepted behaviour and abuse varies across cultures.
Similarly, some cultural practices (e.g., female genital mutilation) are so extreme as to constitute abuse in the United States.
However, some folk remedies (e.g., coining, cupping, irritant compresses) can often create injuries (e.g., bruising, petechiae, minor burns) that may cross the line between acceptable cultural practices and abuse.
Members of some religious and cultural groups have sometimes prevented access to life-saving treatment (e.g. for diabetic ketoacidosis or meningitis), resulting in the death of a child.
Such an impediment is generally considered abandonment regardless of the intentions of the parents or guardians.
In addition, in the United States, there are increasing numbers of people and cultural groups who refuse to vaccinate their children, citing safety concerns ( Vaccination hesitation).
It is not clear whether this refusal to vaccinate is genuine health negligence.
However, the refusal, in the face of illness, of a scientifically accepted treatment often requires further investigation and sometimes legal intervention.
Aetiology of child maltreatment
Generally, abuse can be attributed to loss of impulse control in parents or guardians.
Several factors contribute to this.
Family and personality characteristics may play a role.
The parents’ own childhood may have lacked affection and warmth, may not have led to the development of adequate self-esteem or emotional maturity, and, in many cases, involved other forms of maltreatment.
Abusive parents may view their child as a source of unlimited and unconditional affection and look to them for support that they have never received.
As a result, they may have unrealistic expectations that the children have to make up for them, are easily frustrated and have poor impulse control, and may be unable to provide what they have never experienced.
The use of alcohol or drugs can trigger impulsive and uncontrolled behaviour towards their children.
Parental mental disorders can also increase the risk of maltreatment.
An irritable, demanding or hyperactive child may provoke the parents’ anger, as is the case with children with physical or developmental disabilities, who are often more dependent than a child with normal development.
Sometimes, strong emotional bonds do not develop between parents and children.
This lack of bonding is commonly realised in the case of premature or sick infants, separated in infancy from their parents, or with children who are not biologically their own (e.g., stepchildren), increasing the risk of abuse.
Situational stress can elicit abuse, particularly when emotional support from relatives, friends, neighbours or peers is not accessible.
Physical abuse, emotional abuse and neglect are associated with poverty and lower socioeconomic status.
However, all types of abuse, including sexual abuse, occur in all socio-economic groups.
The risk of sexual abuse is increased in children who are cared for by more than one person or by a parent who has several sexual partners.
Neglect usually results from a combination of factors, such as poor parenting and coping skills, unsupportive family systems and stressful life circumstances.
Neglect often occurs in families impoverished by financial or environmental stress, particularly in those where parents also have untreated mental illness (typically depression, bipolar disorder or schizophrenia), use drugs or alcohol, or have limited intellectual capacity.
Children in single-parent families may be at risk of neglect due to lower income and fewer available resources.
Symptomatology of child maltreatment
Symptomatology depends on the nature and duration of the abuse or neglect.
Skin lesions are common and may include
- Handprints or oval finger marks caused by slapping, gripping and shaking
- Long, banded bruises caused by whipping with a belt
- Thin, bowed bruises caused by whipping with an elastic band
- Multiple and small round burns caused by cigarettes
- Symmetrical burns of the upper or lower limbs, or between the buttocks caused by deliberate immersion;
- Bite marks
- Thickened skin or scars at the corners of the mouth caused by gagging
- Patchy alopecia, with variable hair length, caused by hair pulling
However, more commonly, skin signs are unnoticeable (e.g. a small bruise, petechiae on the face and/or neck) (1).
Fractures that are highly indicative of physical abuse are the classic metaphyseal injuries, rib fractures and spinous process fractures.
Fractures most frequently associated with physical abuse include fractures of the skull, long bones and ribs.
In children < 1 year of age, about 75% of fractures are inflicted by others.
Confusion and focal neurological changes may occur in central nervous system trauma.
The absence of visible head injuries does not exclude head trauma, particularly in shaken infants.
These infants may be comatose or stuporous due to brain damage, although there are no visible signs of injury (with the frequent exception of retinal haemorrhage) or they may present with non-specific signs such as irritability and vomiting.
Traumatic injuries to internal thoracic or abdomino-pelvic organs may occur in the absence of visible signs.
Children who are frequently abused are often fearful and irritable and sleep poorly.
They may have symptoms of depression, post-traumatic stress reactions or anxiety.
Sometimes victims of abuse show symptoms similar to those of attention deficit hyperactivity disorder and are misdiagnosed with this disorder.
Violent or suicidal behaviour may occur.
In most cases, children do not spontaneously disclose sexual abuse and rarely exhibit behaviours or physical signs of sexual abuse.
If a disclosure is made, it is usually delayed, sometimes by days or years. In some cases, abrupt or extreme behavioural changes occur.
Aggression or isolation may develop, as well as phobias or sleep disorders.
Some sexually abused children act in ways that are sexually inappropriate for their age.
Physical signs of sexual abuse by penetration may include
- Difficulty walking or sitting
- Bruising or abrasions around the genitals, anus or mouth
- Vaginal discharge, bleeding or itching;
Other manifestations are sexually transmitted infections, and pregnancy.
A few days after the abuse, examination of the genitals, rectum and mouth will probably be normal, but the examiner may find healed lesions or minor changes.
In early childhood, emotional abuse can dampen emotional expressiveness and reduce interest in the environment.
Emotional abuse often leads to growth difficulties and can be misdiagnosed as an intellectual disability or organic disease.
Delayed development of social and language skills often results from inadequate parental stimulation and interaction.
The emotionally abused child may be insecure, anxious, distrustful, shallow in interpersonal relationships, passive and overly concerned with pleasing adults.
Children who are rejected may have very low self-esteem. Children who are terrified or threatened may appear fearful and avoidant.
The emotional consequence on the child usually manifests itself at school age, when he or she develops difficulties in establishing relationships with the teacher and the peer group.
Frequently, the emotional consequences are only appreciated after the child is placed in another environment, or after the aberrant behaviour fades and is replaced by more acceptable behaviour.
Children who are exploited may commit crimes or abuse alcohol and/or drugs.
Malnutrition, fatigue, poor hygiene, lack of adequate clothing and growth difficulties are frequent signs of inadequate food, clothing or protection.
Fasting or exposure to extreme temperatures or climates can result in stunted growth and even death.
Neglect involving inadequate supervision can result in preventable disease or injury.
References on symptomatology
Pierce MC, Kaczor K, Aldridge S, et al: Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 125(1):67-74, 2010. doi: 10.1542/peds.2008-3632
Diagnosis of child maltreatment
- High index of suspicion (e.g., for history that does not match physical examination or atypical types of injuries)
- Supportive, open questions
- Sometimes imaging and laboratory tests
- Referral to authorities for further investigation
Recognising maltreatment as the cause can be difficult, and a high index of suspicion must be maintained.
Due to social biases, abuse is considered less frequent in children living in a 2-parent household with at least a middle income level.
However, child abuse can occur regardless of family composition or socio-economic status.
Sometimes a direct question provides the answers.
Children who have been abused can describe the events and the abuser, but some children, particularly those who have been sexually abused, may have been forced to swear secrecy, threatened, or are so traumatised that they are reluctant to talk about the abuse (and sometimes even deny the abuse when specifically asked).
A medical history including the account of the events should be collected from children and their guardians in a relaxed environment.
Open-ended questions (e.g., “Can you tell me what happened?”) are particularly important in these cases, as closed-ended yes/no questions (e.g., “Did Daddy do this?”, “Did he touch you here?”) can easily lead to the collection of an untruthful history in young children.
Objective examination includes observation of interactions between the child and guardians whenever possible.
Documentation of the history and physical examination should be complete and accurate as far as possible, including the recording of accurate history and photographs of injuries.
Often it is not clear after the initial assessment whether abuse has occurred. In such cases, mandatory reporting of suspected abuse allows the authorities and social workers to investigate; if their assessment confirms abuse, appropriate legal and social interventions can be made.
Both history and physical examination provide clues to abuse.
Features suggestive of abuse in the history are
- Parental reluctance or inability to provide a history of significant injury
- A history inconsistent with the injury (e.g., bruising on the back of the legs attributed to a forward fall) or an apparent stage of resolution (e.g., old injuries described as recent)
- A history that varies depending on the source of information or over time
- An injury history inconsistent with the child’s developmental stage (e.g. trauma from falling out of bed in a too young infant, or from falling down stairs in an infant too young to crawl)
- Inappropriate parental reaction to the severity of the injuries, or excessive concern or indifference
- Delay in seeking treatment for injuries
Main indicators of abuse on objective examination are
- Atypical lesions
- Injuries inconsistent with the stated history
Childhood injuries caused by falls are typically unique and located on the forehead, chin or mouth, or on the extensor surfaces of the limbs, particularly elbows, knees, forearms and shins.
Bruising on the buttocks and back of the legs is extremely rare in falls.
Fractures, except those of the clavicle, fractures of the tibia (from early childhood), and of the distal radius (Colles), are less frequent in falls while playing or from stairs.
No fractures are pathognomonic of violence, but classic metaphyseal injuries, rib fractures (especially posterior and 1st rib), depressed or multiple skull fractures (caused by apparently minor trauma), fractures of the scapula, sternum, and spinous processes, should lead to the suspicion of abuse.
Physical abuse should be considered when an infant who is not walking or at least proceeding by a cruising gait (i.e., walking with the support of objects in the environment) has severe trauma.
Young infants with apparently minor facial injuries should also be assessed further.
Infants may appear normal despite significant head trauma, and acute inflicted head trauma should be part of the differential diagnosis of any lethargic infant.
Other indicators are multiple injuries at different stages of resolution or development; skin lesions with formations indicative of particular sources of injury ( Physical abuse); and repeated injury, which is suggestive of abuse or inadequate supervision.
A mydriasis eye examination and neuroimaging examination are recommended for all children < 1 year with suspected abuse.
Retinal haemorrhages occur in 85-90% of cases of abusive head trauma, compared with < 10% of cases of accidental head trauma.
However, retinal haemorrhages are not pathognomonic of abuse (1). They may also occur following childbirth and persist for up to 4 weeks.
When retinal haemorrhages result from accidental trauma, the mechanism is usually obvious and life-threatening (e.g., severe motor vehicle accident), and haemorrhages are usually few and limited to the posterior poles.
Children < 36 months (in the previous recommendations 24 months) with possible physical abuse should undergo a skeletal survey to highlight previous bone injuries (fractures in various stages of healing or subperiosteal elevations in the long bones). Surveys are rarely performed on children > 3 years of age.
The standard survey includes images of
- Appendicular skeleton: humeri, forearms, hands, femurs, lower legs and feet
- Axial skeleton: thorax (including oblique projections), pelvis, lumbosacral spine, cervical spine, and skull
Conditions causing multiple fractures include osteogenesis imperfecta and congenital syphilis.
The presence of sexually transmitted infections (2) in a child < 12 years of age should lead professionals to a high degree of suspicion about the possibility of sexual abuse.
When a child is a victim of sexual abuse, behavioural changes (e.g. irritability, fear of everything, insomnia) may be the only initial clue.
If sexual abuse is suspected, the perioral and anal regions and external genitalia should be examined for signs of injury.
If the hypothetical abuse is considered to have occurred recently (≤ 96 h), forensic evidence should be collected using an appropriate kit and handled according to the standards required by law ( Examination and collection of evidence).
An assessment using a magnifying light source equipped with a camera, such as a specially equipped colposcope, can be both useful to the examiner and for documentation purposes for legal purposes.
Emotional abuse and neglect
The assessment focuses on general appearance and behaviour to determine whether the child is unable to grow normally.
Teachers and social workers are often the first to recognise neglect.
The doctor may notice a pattern of missed appointments and vaccinations that are not up to date.
Medical neglect of life-threatening conditions or chronic diseases such as asthma or diabetes can lead to a subsequent increase in emergency room visits and poor adherence to recommended dosages of treatments.
References on diagnosis
Maguire SA, Watts PO, Shaw AD, et al: Retinal haemorrhages and related findings in abusive and non-abusive head trauma: A systematic review. Eye (Lond) 27(1):28-36, 2013. doi: 10.1038/eye.2012.213
Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect; American Academy of Pediatrics: The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics 132(2):e558-e567, 2013. doi: 10.1542/peds.2013-1741
Treatment of child maltreatment (child abuse)
Treatment of injuries
- Reporting to the relevant agency
- Creation of a safety plan
- Family counselling and support
- Sometimes removal from the family
The first treatment concerns urgent medical needs (including possible sexually transmitted infections) and the immediate safety of the child.
Referral to a paediatrician specialised in child abuse should be considered.
In both cases of maltreatment and neglect, the approach to the family should be caring rather than punitive.
Doctors and other professionals in contact with children (e.g. nurses, teachers, day-care workers, police) have a duty to report and are required by law in all states to report cases of suspected abuse or neglect (see Mandatory Reporters of Child Abuse and Neglect).
Each state has its own laws.
Members of the general population are encouraged, but not required, to report cases of suspected abuse.
Anyone who reports abuse based on reasonable evidence and in good faith is exempt from criminal and civil liability.
A staff member with a reporting obligation who fails to make a report may face criminal and civil charges.
Reports are sent to Child Welfare Services or other appropriate child protection centres.
In most situations it is appropriate for health personnel to alert carers that a report has been made in accordance with the law and that they will be contacted, interviewed, and probably visited at home.
In some cases, the caregiver may feel that informing the parents or caregiver before the police or other support service is available creates an increased risk of injury to the child and/or themselves.
In such circumstances, you may choose to delay informing the parent or caregiver.
Child welfare service representatives and social workers conduct an assessment of the child’s events and circumstances and can help the doctor determine the likelihood of subsequent harm and thus identify the best option for the child.
- Hospitalization for protective purposes
- Placement with relatives or in temporary accommodation (sometimes an entire family is moved out of the home of a violent partner)
- Temporary placement in protection centres
- Return home with timely medical and social service follow-up
The doctor plays an important role in working with social services to advise on the best and safest arrangements for the child.
Health professionals in the United States are often asked to write an impact statement, which is a letter typically addressed to a Child Protective Services employee (who can then bring it to the attention of the court system), about a child who is suspected of being the victim of abuse.
The letter should contain a clear statement of the medical history and examination results (in plain language) and an opinion on the possibility that the child has been abused.
A primary medical care centre is essential.
However, families of abused and neglected children often move, making continuity of care difficult.
Missed appointments are frequent; awareness-raising and home visits by social workers and/or public health nurses can be helpful.
A local child support centre can help community agencies, health professionals and legal practitioners to work together as a multidisciplinary team in a more coordinated, child-friendly and effective way.
Careful monitoring of the family environment and the needs of carers is essential, following contact with various public services.
A social worker can carry out this check and help by talking to and interviewing the family.
Social workers also offer tangible assistance to carers by helping them to obtain public assistance, childcare and special care (which can reduce stress in carers).
They can also help coordinate mental health services for caregivers.
Regular or ongoing contact with social workers is usually necessary.
Parent support programmes, which employ non-specialist staff who support parents who abuse and mistreat their children and provide an example of appropriate parenting, are available in some communities.
Other parent support groups have also been effective.
Sexual abuse can lead to permanent effects on child development and future sexual adjustment, especially on older children and adolescents.
Counselling or psychotherapy for the child and the adult involved can lessen these consequences.
Physical abuse, particularly significant head trauma, can also have lasting effects on development.
If doctors or caregivers are concerned that children have a disability or developmental delay, they may request an assessment by an early intervention system of their state (see Early Intervention Services), which is a programme to assess and treat children with suspected disabilities or developmental delays.
Removal from the family
Although temporary emergency removal from the home is sometimes made until the assessment is complete and safety is established, the ultimate goal of childcare services is to keep children with their families in a safe and healthy environment.
Often, families are offered services in which caregivers are rehabilitated so that children who have been removed can be reunited with their families.
If the interventions described above cannot ensure safety, long-term removal and perhaps termination of parental authority must be considered.
This important step requires a court petition, filed by the legal representative of the appropriate welfare department.
The specific procedure varies from state to state, but usually involves an expert opinion on the family by a doctor.
When the court decides to remove the child from the family, an operational plan is established, usually a temporary placement, such as foster care.
While the child is in temporary foster care, the child’s doctor or a team of doctors who specialise in children in foster care should, if possible, maintain contact with the parents and ensure that everything is being done to help them.
Occasionally, children are abused again while in foster care.
The practitioner must be alert to this possibility.
When the dynamics of family relationships improve, the child may return to the care of the original caregiver.
However, relapses of maltreatment are frequent.
Prevention of child maltreatment
Prevention of abuse should be included in every child health service visit through education of parents, guardians, and children and identification of risk factors.
Families at risk should be referred to appropriate social services.
Parents who have been victims of maltreatment have an increased risk of abusing their child.
These parents sometimes express anxiety about their abuse history and are available for assistance.
First-time and adolescent parents as well as parents with many children under 5 years of age also have an increased risk of abusing their children.
Often, maternal risk factors for abuse are identified in the prenatal period (e.g., a mother who smokes, abuses drugs, or has a positive history of domestic violence).
Medical problems occurring during pregnancy, birth or early childhood that may undermine the health of the mother and/or infant can weaken the parent-child bond.
During these periods it is important to detect the parents’ feelings of inadequacy about themselves and the child’s state of well-being.
How well can they tolerate an infant with many needs or health problems? Do the parents offer moral and physical support to each other?
Are there relatives or friends who can help them in times of need?
A doctor who is alert to early signs and able to provide support can have a greater impact on the family and possibly prevent child abuse.
Mandatory Reporters of Child Abuse and Neglect: Information on who is required to report state abuse in the United States.
Early Intervention Services: US government services for infants and toddlers
Child Welfare Information Gateway: U.S. government child welfare information portal containing guidance on many aspects of child abuse, as well as listings of state and federal resources
Child Welfare Information Gateway: Child Abuse and Neglect: Information specific to child abuse, including definitions, identification, risk factors, mandatory reporting and more
Prevent Child Abuse America: Children’s charity focusing on child abuse with lots of useful information for parents and caregivers and information on public policy