Abused and Neglected Children

Definitions

Abuse is defined as acts of commission and neglect as acts of omission. The U.S. government defines child abuse as “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” Some states also include other household members. Children may be found in situations in which no actual harm has occurred, and no imminent risk of serious harm is evident, but potential harm may be a concern. Many states include potential harm in their child abuse laws. Consideration of potential harm enables preventive intervention, although predicting potential harm is inherently difficult. Two aspects should be considered: the likelihood of harm and the severity of that harm.

Physical abuse includes beating, shaking, burning, and biting. Corporal punishment , however, is increasingly being prohibited. The Global Initiative to End All Corporal Punishment of Children reported that 52 countries have prohibited corporal punishment in all settings, including the home. Governments in 55 other countries have expressed a commitment to full prohibition. In the United States, corporal punishment in the home is lawful in all states, but 31 states have banned corporal punishment in public.

The threshold for defining corporal punishment as abuse is unclear. One can consider any injury beyond transient redness as abuse. If parents spank a child, it should be limited to the buttocks, should occur over clothing, and should never involve the head and neck. When parents use objects other than a hand, the potential for serious harm increases. Acts of serious violence (e.g., throwing a hard object, slapping an infant's face) should be seen as abusive even if no injury ensues; significant risk of harm exists. While some child healthcare professionals think that hitting is acceptable under limited conditions, almost all know that more constructive approaches to discipline are preferable. The American Academy of Pediatrics clearly opposed the use of corporal punishment in a recent policy statement. Although many think that hitting a child should never be accepted, and many studies have documented the potential harm, there remains a reluctance in the United States to label hitting as abuse, unless there is an injury. It is clear that the emotional impact of being hit may leave the most worrisome scar, long after the bruises fade and the fracture heals.

Sexual abuse has been defined as “the involvement of dependent, developmentally immature children and adolescents in sexual activities which they do not fully comprehend, to which they are unable to give consent, or that violate the social taboos of family roles.” Sexual abuse includes exposure to sexually explicit materials, oral-genital contact, genital-to-genital contact, genital-to-anal contact, and genital fondling. Any touching of private parts by parents or caregivers in a context other than necessary care is inappropriate.

Neglect refers to omissions in care, resulting in actual or potential harm. Omissions include inadequate healthcare, education, supervision, protection from hazards in the environment, and unmet physical needs (e.g., clothing, food) and emotional support. A preferable alternative to focusing on caregiver omissions is to instead consider the basic needs (or rights) of children (e.g., adequate food, clothing, shelter, healthcare, education, nurturance). Neglect occurs when a need is not adequately met and results in actual or potential harm, whatever the reasons. A child whose health is jeopardized or harmed by not receiving necessary care experiences medical neglect . Not all such situations necessarily require a report to child protective services (CPS); less intrusive initial efforts may be appropriate.

Psychological abuse includes verbal abuse and humiliation and acts that scare or terrorize a child. Although this form of abuse may be extremely harmful to children, resulting in depression, anxiety, poor self-esteem, or lack of empathy, CPS seldom becomes involved because of the difficulty in proving such allegations. Child healthcare professionals should still carefully consider this form of maltreatment, even if the concern fails to reach a legal or agency threshold for reporting. These children and families can benefit from counseling and social support. Many children experience more than one form of maltreatment; CPS are more likely to address psychological abuse in the context of other forms of maltreatment.

Within in the United States and internationally, problems of trafficking in children, for purposes of cheap labor and sexual exploitation, expose children to all the forms of abuse just noted (see Chapter 15 ).

Incidence and Prevalence

Global

Child abuse and neglect are not rare and occur worldwide. Based on international studies, the World Health Organization (WHO) has estimated that 18% of girls and 8% of boys experience sexual abuse as children, while 23% of children report being physically abused ( Figs. 16.1 and 16.2 ). In addition, many children experience emotional abuse and neglect. Surveys reported by United Nations Children's Fund (UNICEF) confirm these reports; one survey conducted in the Middle East reported that 30% of children had been beaten or tied up by parents, and in a survey in a Southeast Asian country, 30% of mothers reported having hit their child with an object in the past 6 mo.

Etiology

Child maltreatment seldom has a single cause; rather, multiple and interacting biopsychosocial risk factors at 4 levels usually exist. To illustrate, at the individual level , a child's disability or a parent's depression or substance abuse predispose a child to maltreatment. At the familial level , intimate partner (or domestic) violence presents risks for children. Influential community factors include stressors such as dangerous neighborhoods or a lack of recreational facilities. Professional inaction may contribute to neglect, such as when the treatment plan is not clearly communicated. Broad societal factors , such as poverty and its associated burdens, also contribute to maltreatment. WHO estimates the rate of homicide of children is approximately 2-fold higher in low-income compared to high-income countries (2.58 vs 1.21 per 100,000 population), but clearly homicide occurs in high-income countries too. Children in all social classes can be maltreated, and child healthcare professionals need to guard against biases concerning low-income families.

In contrast, protective factors , such as family supports, or a mother's concern for her child, may buffer risk factors and protect children from maltreatment. Identifying and building on protective factors can be vital to intervening effectively. One can say to a parent, “I can see how much you love [child's name]. What can we do to keep her out of the hospital?” Child maltreatment results from a complex interplay among risk and protective factors. A single mother who has a colicky baby and who recently lost her job is at risk for maltreatment, but a loving grandmother may be protective. A good understanding of factors that contribute to maltreatment, as well as those that are protective, should guide an appropriate response.

Clinical Manifestations

Child abuse and neglect can manifest in many ways. A critical element of physical abuse is the lack of a plausible history other than inflicted trauma. The onus is on the clinician to carefully consider the differential diagnosis and not jump to conclusions.

Bruises are the most common manifestation of physical abuse. Features suggestive of inflicted bruises include (1) bruising in a preambulatory infant (occurring in just 2% of infants), (2) bruising of padded and less exposed areas (buttocks, cheeks, ears, genitalia), (3) patterned bruising or burns conforming to shape of an object or ligatures around the wrists, and (4) multiple bruises, especially if clearly of different ages ( Fig. 16.3 and Table 16.1 ). Earlier suggestions for estimating the age of bruises have been discredited. It is very difficult to precisely determine the ages of bruises.

Other conditions such as birthmarks and congenital dermal melanocytosis (e.g., mongolian spots) can be confused with bruises and abuse. These skin markings are not tender and do not rapidly change color or size. An underlying medical explanation for bruises may exist, such as blood dyscrasias (hemophilia) or connective tissue disorders (Ehlers-Danlos syndrome). The history or examination usually provides clues to these conditions. Henoch-Schönlein purpura, the most common vasculitis in young children, may be confused with abuse. The pattern and location of bruises caused by abuse are usually different from those due to a coagulopathy. Noninflicted bruises are characteristically anterior and over bony prominences, such as shins and forehead. The presence of a medical disorder does not preclude abuse.

Cultural practices can cause bruising. Cao gio, or coining, is a Southeast Asian folkloric therapy. A hard object is vigorously rubbed on the skin, causing petechiae or purpura. Cupping is another approach, popular in the Middle East. A heated glass is applied to the skin, often on the back. As it cools, a vacuum is formed, leading to perfectly circular bruises. The context here is important, and such circumstances should not be considered abusive (see Chapter 11 ).

A careful history of bleeding problems in the patient and first-degree relatives is needed. If a bleeding disorder is suspected, a complete blood count including platelet count, prothrombin time, and partial thromboplastin time should be obtained. More extensive testing, such as factors VIII, IX and XIII activity and von Willebrand evaluation, should be considered in consultation with a hematologist.

Bites have a characteristic pattern of 1 or 2 opposing arches with multiple bruises. They can be inflicted by an adult, another child, an animal, or the patient. Forensic odontologists have previously developed guidelines for distinguishing adult from child and human from animal bites. However, several studies have identified problems with the accuracy and consistency of bite mark analysis.

Burns may be inflicted or caused by inadequate supervision. Scalding burns may result from immersion or splash. Immersion burns, when a child is forcibly held in hot water, show clear delineation between the burned and healthy skin and uniform depth. They may have a sock or glove distribution. Splash marks are usually absent, unlike when a child inadvertently encounters hot water. Symmetric burns are especially suggestive of abuse, as are burns of the buttocks and perineum ( Fig. 16.4 ). Although most often accidental, splash burns may also result from abuse. Burns from hot objects such as curling irons, radiators, steam irons, metal grids, hot knives, and cigarettes leave patterns representing the object ( Fig. 16.5 ). A child is likely to draw back rapidly from a hot object; thus burns that are extensive and deep reflect more than fleeting contact and are suggestive of abuse.

Several conditions mimic abusive burns, such as brushing against a hot radiator, car seat burns, hemangiomas, and folk remedies such as moxibustion. Impetigo may resemble cigarette burns. Cigarette burns are usually 7-10 mm across, whereas impetigo has lesions of varying size. Noninflicted cigarette burns are usually oval and superficial.

Neglect frequently contributes to childhood burns. Children, home alone, may be burned in house fires. A parent taking drugs may cause a fire and may be unable to protect a child. Exploring children may pull hot liquids left unattended onto themselves. Liquids cool as they flow downward so that the burn is most severe and broad proximally. If the child is wearing a diaper or clothing, the fabric may absorb the hot water and cause burns worse than otherwise expected. Some circumstances are difficult to foresee, and a single burn resulting from a momentary lapse in supervision should not automatically be seen as neglectful parenting.

Concluding whether a burn was inflicted depends on the history, burn pattern, and the child's capabilities. A delay in seeking healthcare may result from the burn initially appearing minor, before blistering or becoming infected. This circumstance may represent reasonable behavior and should not be automatically deemed neglectful. A home investigation is often valuable (e.g., testing the water temperature).

Fractures that strongly suggest abuse include classic metaphyseal lesions, posterior rib fractures, and fractures of the scapula, sternum, and spinous processes, especially in young children ( Table 16.2 ). These fractures all require more force than would be expected from a minor fall or routine handling and activities of a child. Rib and sternal fractures rarely result from cardiopulmonary resuscitation (CPR), even when performed by untrained adults. The recommended 2-finger or 2-thumb technique recommended for infants since 2005 may produce anterolateral rib fractures. In abused infants, rib ( Fig. 16.6 ), metaphyseal ( Fig. 16.7 ), and skull fractures are most common. Femoral and humeral fractures in nonambulatory infants are also very worrisome for abuse. With increasing mobility and running, toddlers can fall with enough rotational force to cause a spiral, femoral fracture. Multiple fractures in various stages of healing are suggestive of abuse; nevertheless, underlying conditions need to be considered. Clavicular, femoral, supracondylar humeral, and distal extremity fractures in children older than 2 yr are most likely noninflicted unless they are multiple or accompanied by other signs of abuse. Few fractures are pathognomonic of abuse; all must be considered in light of the history and the child's developmental level. Fractures may present as an irritable fussy child.

The differential diagnosis includes conditions that increase susceptibility to fractures, such as osteopenia and osteogenesis imperfecta, metabolic and nutritional disorders (e.g., scurvy, rickets), renal osteodystrophy, osteomyelitis, congenital syphilis, and neoplasia. Some have pointed to possible rickets and low but subclinical levels of vitamin D as being responsible for fractures thought to be abusive. The evidence to date does not support this supposition. Features of congenital or metabolic conditions associated with nonabusive fractures include family history of recurrent fractures after minor trauma, abnormally shaped cranium, dentinogenesis imperfecta, blue sclera, craniotabes, ligamentous laxity, bowed legs, hernia, and translucent skin. Subperiosteal new bone formation is a nonspecific finding seen in infectious, traumatic, and metabolic disorders. In young infants, new bone formation may be a normal physiologic finding, usually bilateral, symmetric, and <2 mm in depth.

The evaluation of a fracture should include a skeletal radiologic survey in children <2 yr old when abuse seems possible ( Table 16.3 ). Multiple radiographs with different views are needed; “babygrams” (1 or 2 films of the entire body) should be avoided. If the survey is normal, but concern for an occult injury remains, a radionucleotide bone scan should be performed to detect a possible acute injury. Follow-up films after 2 wk may also reveal fractures not apparent initially.

In corroborating the history and the injury, the age of a fracture can be crudely estimated ( Table 16.4 ). Soft tissue swelling subsides in 2-21 days. Subperiosteal new bone is visible within 6-21 days. Loss of definition of the fracture line occurs in 10-21 days. Soft callus can be visible after 9 days and hard callus at 14-90 days. These ranges are shorter in infancy and longer in children with poor nutritional status or a chronic underlying disease. Fractures of flat bones such as the skull do not form callus and cannot be aged, although soft tissue swelling indicates approximate recency (within the prior week).

Abusive head trauma (AHT) results in the most significant morbidity and mortality. Abusive injury may be caused by direct impact, asphyxia, or shaking. Subdural hematomas ( Fig. 16.8 ), retinal hemorrhages, especially when extensive and involving multiple layers, and diffuse axonal injury strongly suggest AHT, especially when they occur together. The poor neck muscle tone and relatively large heads of infants make them vulnerable to acceleration-deceleration forces associated with shaking, leading to AHT. Children may lack external signs of injury, even with serious intracranial trauma. Signs and symptoms may be nonspecific, ranging from lethargy, vomiting (without diarrhea), changing neurologic status or seizures, and coma. In all preverbal children, an index of suspicion for AHT should exist when children present with these signs and symptoms.

Acute intracranial trauma is best evaluated by initial and follow-up CT. MRI is helpful in differentiating extra axial fluid, determining timing of injuries, assessing parenchymal injury, and identifying vascular anomalies. MRI is best obtained 5-7 days after an acute injury. Glutaric aciduria type 1 can present with intracranial bleeding and should be considered. Other causes of subdural hemorrhage in infants include arteriovenous malformations, coagulopathies, birth trauma, tumor, and infections. When AHT is suspected, injuries elsewhere—skeletal and abdominal—should be ruled out.

Retinal hemorrhages are an important marker of AHT ( Fig. 16.9 ). Whenever AHT is being considered, a dilated indirect eye examination by a pediatric ophthalmologist should be performed. Although retinal hemorrhages can be found in other conditions, hemorrhages that are multiple, involve >1 layer of the retina, and extend to the periphery are very suspicious for abuse. The mechanism is likely repeated acceleration-deceleration from shaking. Traumatic retinoschisis points strongly to abuse.

With other causes of retinal hemorrhages, the pattern is usually different than seen in child abuse. After birth, many newborns have them, but they disappear in 2-6 wk. Coagulopathies (particularly leukemia), retinal diseases, carbon monoxide poisoning, or glutaric aciduria may be responsible. Severe, noninflicted, direct crush injury to the head can rarely cause an extensive hemorrhagic retinopathy. CPR rarely, if ever, causes retinal hemorrhage in infants and children; if present, there a few hemorrhages in the posterior pole. Hemoglobinopathies, diabetes mellitus, routine play, minor noninflicted head trauma, and vaccinations do not appear to cause retinal hemorrhage in children. Severe coughing or seizures rarely cause retinal hemorrhages that could be confused with AHT.

The dilemma frequently posed is whether minor, everyday forces can explain the findings seen in AHT. Simple linear skull fractures in the absence of other suggestive evidence can be explained by a short fall, although even that is rare (1-2%), and underlying brain injury from short falls is exceedingly rare. Timing of brain injuries in cases of abuse is not precise. In fatal cases, however, the trauma most likely occurred very soon before the child became symptomatic.

Other manifestations of AHT may be seen. Raccoon eyes occur in association with subgaleal hematomas after traction on the anterior hair and scalp, or after a blow to the forehead. Neuroblastoma can present similarly and should be considered. Bruises from attempted strangulation may be visible on the neck. Choking or suffocation can cause hypoxic brain injury, often with no external signs.

Abdominal trauma accounts for significant morbidity and mortality in abused children. Young children are especially vulnerable because of their relatively large abdomens and lax abdominal musculature. A forceful blow or kick can cause hematomas of solid organs (liver, spleen, kidney) from compression against the spine, as well as hematoma (duodenal) or rupture (stomach) of hollow organs. Intraabdominal bleeding may result from trauma to an organ or from shearing of a vessel. More than 1 organ may be affected. Children may present with cardiovascular failure or an acute condition of the abdomen, often after a delay in care. Bilious vomiting without fever or peritoneal irritation suggests a duodenal hematoma, often caused by abuse.

The manifestations of abdominal trauma are often subtle, even with severe injuries. Bruising of the abdominal wall is unusual, and symptoms may evolve slowly. Delayed perforation may occur days after the injury; bowel strictures or a pancreatic pseudocyst may occur weeks or months later. Child healthcare professionals should consider screening for occult abdominal trauma when other evidence of physical abuse exists. Screening should include liver and pancreatic enzyme levels, and testing urine for blood. Children with lab results indicating possible injury should have abdominal CT performed. CT or ultrasound should also be performed if there is concern about possible splenic, adrenal, hepatic, or reproductive organ injury.

Oral lesions may present as bruised lips, bleeding, torn frenulum, and dental trauma or caries (neglect).

General Principles for Assessing Possible Abuse and Neglect

The heterogeneity of circumstances in situations of child maltreatment precludes specific detailing of varied assessments. The following are useful general principles.

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  Given the complexity and possible ramifications of determining child maltreatment, an interdisciplinary assessment is optimal, with input from all involved professionals. Consultation with a physician expert in child maltreatment is recommended.

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  A thorough history should be obtained from the parent(s) optimally via separate interviews.

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  Verbal children should be interviewed separately, in a developmentally appropriate manner. Open-ended questions (e.g., “Tell me what happened”) are best. Some children need more directed questioning (e.g., “How did you get that bruise?”); others need multiple-choice questions. Leading questions must be avoided (e.g., “Did your daddy hit you?”).

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  A thorough physical examination is necessary.

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  Careful documentation of the history and physical is essential. Verbatim quotes are valuable, including the question that prompted the response. Photographs are helpful.

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  For abuse : What is the evidence for concluding abuse? Have other diagnoses been ruled out? What is the likely mechanism of the injury? When did the injury likely occur?

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  For neglect : Do the circumstances indicate that the child's needs have not been adequately met? Is there evidence of actual harm? Is there evidence of potential harm and on what basis? What is the nature of the neglect? Is there a pattern of neglect?

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  Are there indications of other forms of maltreatment? Has there been prior CPS involvement?

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  A child's safety is a paramount concern. What is the risk of imminent harm, and of what severity?

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  What is contributing to the maltreatment? Consider the categories described in the section on etiology.

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  What strengths/resources are there? This is as important as identifying problems.

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  What interventions have been tried, with what results? Knowing the nature of these interventions can be useful, including from the parent's perspective.

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  What is the prognosis ? Is the family motivated to improve the circumstances and accept help, or resistant? Are suitable resources, formal and informal, available?

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  Are there other children in the home who should be assessed for maltreatment?

General Principles for Addressing Child Maltreatment

The heterogeneity of circumstances also precludes specific details regarding how to address different types of maltreatment. The following are general principles.

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  Treat any medical problems.

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  Help ensure the child's safety , often in conjunction with CPS; this is a priority.

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  Convey concerns of maltreatment to parents, kindly but forthrightly. Avoid blaming. It is natural to feel anger toward parents of maltreated children, but they need support and deserve respect.

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  Have a means of addressing the difficult emotions child maltreatment can evoke.

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  Be empathic, and state interest in helping or suggest another pediatrician.

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  Know your national and state laws and/or local CPS policies on reporting child maltreatment. In the United States, the legal threshold for reporting is typically “reason to believe” (or similar language such as “reason to suspect”); one does not need to be certain. Physical abuse and moderate to severe neglect warrant a report. In less severe neglect, less intrusive interventions may be an appropriate initial response. For example, if an infant's mild failure to thrive is caused by an error in mixing the formula, parent education and perhaps a visiting nurse should be tried. In contrast, severe failure to thrive may require hospitalization, and if the contributing factors are particularly serious (e.g., psychotic mother), out-of-home placement may be needed. CPS can assess the home environment, providing valuable insights.

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  Reporting child maltreatment is never easy. Parental inadequacy or culpability is at least implicit, and parents may express considerable anger. Child healthcare professionals should supportively inform families directly of the report; it can be explained as an effort to clarify the situation and provide help, as well as a professional (and legal) responsibility. Explaining what the ensuing process is likely to entail (e.g., a visit from a CPS worker and sometimes a police officer) may ease a parent's anxiety. Parents are frequently concerned that they might lose their child. Child healthcare professionals can cautiously reassure parents that CPS is responsible for helping children and families and that, in most instances, children remain with their parents. When CPS does not accept a report or when a report is not substantiated, they may still offer voluntary supportive services such as food, shelter, parenting resources, and childcare. Child healthcare professionals can be a useful liaison between the family and the public agencies and should try to remain involved after reporting to CPS.

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  Help address contributory factors, prioritizing those most important and amenable to being remedied. Concrete needs should not be overlooked; accessing nutrition programs, obtaining health insurance, enrolling children in preschool programs, and help finding safe housing can make a valuable difference. Parents may need their own problems addressed to enable them to provide adequate care for their children.

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  Establish specific objectives (e.g., no hitting, diabetes will be adequately controlled), with measurable outcomes (e.g., urine dipsticks, hemoglobin A1c). Similarly, advice should be specific and limited to a few reasonable steps. A written contract can be very helpful.

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  Engage the family in developing the plan, solicit their input and agreement.

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  Build on strengths ; there are always some. These provide a valuable way to engage parents.

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  Encourage informal supports (e.g., family, friends; invite fathers to office visits). This is where most people get their support, not from professionals. Consider support available through a family's religious affiliation.

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  Consider children's specific needs . Too often, maltreated children do not receive direct services.

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  Be knowledgeable about community resources, and facilitate appropriate referrals.

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  Provide support, follow-up, review of progress, and adjust the plan if needed.

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  Recognize that maltreatment often requires long-term intervention with ongoing support and monitoring.