What is Child Abuse and Neglect?
The World Health Organization (WHO) describes child maltreatment as various forms of physical harm, emotional damage, neglect, and exploitation which could potentially damage a child’s health, dignity, or development. There are four major kinds of abuse: neglect, physical abuse, emotional abuse, and sexual abuse. Abuse is an act of harmful action, while neglect is when necessary care is left undone, leading to possible harm.
Neglect can involve lack of proper healthcare, education, supervision, safety measures, or essential needs like food and clothing. It’s the most typical form of child abuse. Physical abuse can consist of actions like hitting, shaking, burning, or biting. However, it’s hard to define when corporal punishment becomes abuse. For instance, rib fractures are the most common injury linked to physical abuse.
Psychological abuse includes actions like verbal abuse, humiliation, or behaviors that frighten a child, which could lead to future mental health issues. Sexual abuse is when children are involved in sexual activities which they don’t fully understand, can’t consent to, or breach social norms. Sexual abuse doesn’t always involve penetration and can also include exposure to explicit materials or other forms of sexual contact.
Unfortunately, many child abuse cases are often overlooked by healthcare professionals. For a diagnosis of child abuse to be made, it requires a high level of suspicion.
What Causes Child Abuse and Neglect?
Child abuse affects all races, ethnic groups, and social classes. However, it is more prevalent in boys and teenagers. Infants who experience physical abuse are more likely to suffer serious health problems or even death. Various factors can increase a child’s likelihood of experiencing abuse. These can be personal factors like a disability, having an unmarried mother, the mother smoking, or a parent suffering from depression.
Other risk factors can exist at the family level, such as domestic violence at home or having more than two siblings. At the community level, a lack of recreational facilities can contribute to the risk. Societal factors like poverty are also significant. Other risks include living in a home with unrelated adults or being a child that has been previously reported to child protective services. All of these increase the chances of child maltreatment.
However, there are also protective factors that can reduce the risk of child maltreatment. These include family support and parents who are aware and concerned about their child’s wellbeing. Also, teaching parents about a child’s developmental needs and good parenting practices, providing social support, and building parental resilience can further prevent the risk of abuse.
Risk Factors and Frequency for Child Abuse and Neglect
Every year, Child Protective Services looks into potential cases of child abuse and neglect involving millions of kids. In 2014 alone, more than 3.2 million children were part of these child mistreatment investigations. Out of these kids, about 20% were confirmed to have signs of maltreatment.
Signs and Symptoms of Child Abuse and Neglect
Identifying child maltreatment is challenging because the child may be too scared or hurt to speak, and often, there aren’t any witnesses. On top of this, the person causing harm is unlikely to confess. Children who have faced maltreatment can come into contact with doctors under various circumstances, such as when a responsible adult brings them for a checkup due to concern, they themselves report the abuse, or accidentally get noticed during unrelated medical care.
A diagnosis of physical child abuse should be considered when examining a child for any kind of injury. Comprehensive understanding of the child’s behavior before, during, and after the injury is crucial to make the correct diagnosis. It’s necessary to gather this information by interviewing each caregiver and the child separately. The person giving the history should not be interrupted to avoid influencing their account.
When looking for signs of physical child abuse, keep an eye out for:
- Any injury in a non-moving infant
- Injury in a non-speaking child
- Injury inconsistent with a child’s physical abilities
- Unlikely injury mechanisms and multiple injuries
- Bruises on the torso, ear, or neck of a child under 4
- Burns to genitalia
- Unconcerned caregiver
- Unusual delay in seeking care or inconsistencies in the provided history
Bruising is the most common sign of physical abuse. In physically abused children, most bruises occur on the head and face. Non-ambulatory children should not usually have bruises, so any bruising on them could indicate abuse. Burns that have keen boundaries and cover symmetrical areas, especially the genitals and legs, can also hint at physical abuse.
Abusive Head Trauma or ‘shaken baby syndrome’ has a high death rate (over 20%). Symptoms can range from vomiting to unresponsiveness, seizures, or coma. The key indicators of this are particular types of bleeding in the eyes, blood build-up under the dura mater in the brain, and diffuse axonal injury where the brain’s white matter is damaged.
Most commonly, child abuse shows up as neglect, with fractures being very common, especially in non-ambulatory children under 18 months old. Though no fracture is definitive for abuse, some, like rib fractures, and fractures at the ends of long bones, can highly suggest abuse. Other suspicious fractures are those of the sternum, spine, and shoulder blades.
Abdominal injuries are a serious consequence of child abuse that can lead to severe health issues and death. Screening for these should include certain routine tests and an abdominal CT scan if any test results are positive.
Sexual abuse symptoms can be indirect, like a child undressing around others. Importantly, even if a physical examination doesn’t find anything unusual, it doesn’t mean sexual abuse hasn’t happened. The most valuable evidence of sexual abuse is often the child’s own statement.
Neglect can show up as poor oral hygiene, malnutrition, untreated wounds or diaper rash. As mandated reporters, healthcare providers must report whenever they reasonably suspect abuse or neglect. Often this can save a child’s life, and it’s always best to involve a child abuse specialist for a thorough investigation.
Testing for Child Abuse and Neglect
If there are concerns about physical abuse in a child younger than two years old, the child should undergo an examination called a skeletal survey. This test should also be conducted on any sibling younger than two years of age if there’s an abused child in the family. A skeletal survey is an imaging study that includes 21 specific views or angles of the child’s body, as recommended by the American College of Radiology. It covers anterior (front) and lateral (side) views of the skull, lateral view of the spine, different views of chest, pelvis, thighs, legs, upper arms, forearms, hands and feet.
If the initial findings from this survey are unclear or abnormal, it’s necessary to conduct another survey after 2 weeks to keep track of healing processes.
In addition to these imaging tests, doctors may require laboratory tests to rule out other health conditions that might be causing the symptoms. These tests can examine bone health, blood health, clotting ability, metabolic functioning, liver health, pancreatic functioning, and bleeding tendencies.
However, it’s important to remember that the most common explanation or alternative diagnosis for injuries seen as non-accidental is accidental injury. This means that the injuries may be due to an accident rather than abuse.
Treatment Options for Child Abuse and Neglect
The first step in helping a child who might be a victim of abuse is to make sure the child is safe and healthy. This includes checking vital signs like breathing and heart rate. Once the child’s physical health is stable, doctors will take a full medical history and conduct a physical exam. If there is any suspicion of child abuse, Child Protective Services need to be informed. It’s also beneficial if a specialist in child abuse is involved in the case. If the initial consultation happens at a clinic or other outpatient location, the child might need to be taken to a hospital. Here, they can get further tests and the appropriate care required. Importely, even if a child is then seen by another health professional or at a different location, the first doctor who saw the child still has a duty to report the potential abuse. While it’s not a doctor’s job to identify who might have abused the child, it is their job to recognize signs of possible abuse and advocate for the child.
In the case of sexual abuse, it’s important to look after the child’s physical and mental health, as well as their social well-being. Teen victims should be tested for sexually transmitted infections (STIs) and pregnancy. They might also get treatment to prevent HIV and other STIs, as well as emergency contraception if they want it. These measures work best if the child gets help within 72 hours of the incident. Younger children at the prepubertal stage are generally not given these preventive treatments because the chance of having an STI is lower at this age. If the child has been sexually abused, it’s especially important to get them help quickly if they’ve been injured, to gather evidence, and for their protection. Fast help is also crucial if the child is having thoughts of suicide or has other immediate medical needs.
What else can Child Abuse and Neglect be?
Here are some health conditions that may cause certain abnormalities in the body:
- Idiopathic thrombocytopenic purpura – a disorder that can lead to easy or excessive bruising and bleeding
- Malignancy – the presence of a dangerous and harmful growth in the body (cancer)
- Vascular malformations – abnormalities in the blood vessels
- Collagen vascular disorder – a group of diseases affecting the connective tissues in the body
- Osteogenesis imperfecta – a genetic disorder causing bones to break easily
- Hemophilia – a rare disorder where blood does not clot properly, causing excessive bleeding
Possible Complications When Diagnosed with Child Abuse and Neglect
There are several potential consequences which might occur as a result of various incidents or conditions, including:
- Fractures or broken bones
- Burns
- Disfigurement or physical changes
- Emotional trauma
- Seizures
- Mental retardation
- PTSD (Post Traumatic Stress Disorder)
