New York State Child Abuse, Maltreatment, and Neglect

Etiology

All races, ethnicities, and socioeconomic groups may be affected by child abuse, with boys and adolescents more commonly affected. Infants have increased morbidity and mortality with physical abuse. Factors that increase a child's risk of abuse include:

• Individual factors of respondent or child: a child's disability, single parent, maternal smoking, or a parent's depression
• Familial factors: domestic violence at home, > 2 siblings at home
• Community factors: lack of recreational facilities and other community support
• Societal factors: poverty
• Living in an unrelated adult's home
• Previous report to child protective services (CPS)

Risk Factors that Increase Child Abuse and Maltreatment (Center for Disease Control):[1][5]

• Alcoholism and substance abuse
• Community violence
• Children younger than 4 years of age
• Family disorganization, dissolution, and violence
• Family history of child abuse and maltreatment
• Intellectual disability
• Lack of understanding of development and needs
• Limited education
• A large number of dependent children
• Low income
• Mental health issues
• Parenting stress
• Parental emotions that tend to justify maltreatment
• Physical disability or illness
• Poor parenting skills
• Social isolation
• Single parenthood
• Transient caregivers
• Young age
• Unemployment rates

There are also “protective or preventive factors” that decrease the risk of child maltreatment, including:

• Family support
• Parental concern
• Parental education regarding child development and parenting
• Social support
• Parental resilience.[6][7][8]

Potential Long-term Sequela of Child Abuse[1][5]

• Physical and mental health conditions
• Low life potential
• Premature death
• Substance abuse

Epidemiology

Each year, over 3 million children are investigated nationally by Child Protective Services for child abuse and neglect. Of those, 20% are found to have evidence of maltreatment.[9] 

There are over 150,000 referrals for abuse and neglect in New York State, with nearly half of them confirmed victims. Male and female percentage of victims are similar. The highest risk of abuse and neglect are in children < 3 years of age and in African American and Native American children. Of those abused, approximately 75% are neglected, 15-20% are physically abused, and 5-10% are sexually abused.[1][5][10]

History and Physical

Diagnosis of child abuse, neglect, or maltreatment may be difficult as the victim may be unable to provide information due to pre-verbal or nonverbal status, fear, or severe injuries. Also, the perpetrator rarely admits to the abuse, and witnesses are uncommon. Physicians may see children of maltreatment in a variety of situations that include:

• An adult or mandated reporter brings the child in for evaluation when they are concerned about abuse.
• A child or adolescent comes in disclosing the abuse.
• A perpetrator brings the patient for medical care with concern that the abuse is severe.
• A child presents for care unrelated to abuse, and abuse may be found incidentally.

Physical abuse should be considered in the evaluation of all injuries of children. A thorough history of present illness is vital to make a correct diagnosis. Information about the child's behavior before, during, and after the injury should be obtained. History-taking should include the interview of the verbal child and each caretaker separately. The parent or caretaker should be allowed to provide their history without interruptions to not be influenced by the physician's questions or interpretations.

Pediatric physical abuse should be considered in the following:

• Injury in a non-ambulatory infant
• Injury in a nonverbal child
• Injury inconsistent with the child's physical abilities
• A statement of harm from the verbal child
• Mechanism of injury not plausible
• Multiple injuries, particularly at varying stages of healing
• Bruises on the torso, ear, or neck in a child younger than 4 years of age
• Burns to genitalia
• Stocking or glove distributions or patterns of injury
• The caregiver is unconcerned about the injury.
• An unexplained delay in seeking care
• Inconsistencies or discrepancies in the histories provided 

"TEN 4" is a useful mnemonic to recall which bruising locations are of concern in cases involving physical abuse: bruises of the Torso, Ear, or Neck in a child < 4 years of age or any bruising in a child < 4 months of age are concerning for abuse.

Other injuries that are highly suggestive of abuse include:

• Retinal hemorrhages
• Posterior rib fractures
• Classic metaphyseal lesions[1][5]

Signs And Symptoms Of Child Abuse

Physical Abuse[5]

Pediatric Abusive Head Trauma (PAHT)[11]

Pediatric Abusive Head Trauma (PAHT) or “shaken baby syndrome” is a common cause of abusive head injury in children and is associated with significant morbidity and mortality. PAHT is an injury to the intracranial contents or skull of an infant or young child inflicted by blunt impact or violent shaking. An evaluation may begin with a skull X-ray or head ultrasound but often requires a head CT for definitive diagnosis, particularly in an emergency setting or in an unstable child. Common head CT findings in PAHT include subdural hematomas and diffuse axonal injury. The evaluation should also include an ophthalmologic examination to evaluate for retinal hemorrhages.

Signs and symptoms of PAHT are often non-specific and may include:

• Absence of hair due to vigorous hair pulling
• Apnea
• Bulging fontanelles
• Coma
• Decreased appetite
• Irritability
• Unexplained injury to the frenulum, jaw, nose, or teeth
• Lethargy
• Retinal hemorrhages
• Seizures
• Vomiting

Long term sequela of PAHT includes:

• Blindness
• Cerebral palsy
• Developmental delay
• Hearing loss
• Learning difficulties
• Seizures

Glutaric aciduria type 1 is a rare metabolic disease that can cause retinal hemorrhages and subdural hematomas and may be mistaken for PAHT.

Skeletal Trauma

The majority of abusive fractures occur in non-ambulatory infants and toddlers < 18 months of age. Any unexplained fracture in a child should raise suspicion for child abuse. The following fractures may be concerning for physical abuse:

• Skull fractures
• "Bucket handle" fractures or "corner" fractures due to twisting of the ends of the long bones.
• Long bone fractures in a non-ambulatory child
• Greenstick fractures
• Posterior or lateral rib fractures
• Scapular fractures other than those caused by birth trauma
• Spinal fractures
• Sternal fractures
• Multiple fractures in various stages of healing
• Facial fractures
• Skeletal trauma with other injuries

Symptoms that raise suspicion for fracture include:

• Red, swollen, painful joint or limb
• Patient crying with pain or irritability
• Local tenderness to palpation
• Unwillingness to move the limb

Organic causes of fractures that may be mistaken for child abuse include:

• Osteogenesis imperfecta
• Osteopenia
• Metabolic bone disease: Rickets, vitamin C and copper deficiency
• Oncological disorders
• Ehlers-Danlos syndrome
• Injury sustained during resuscitation: rib fractures, internal organ contusions, retinal hemorrhages[12]

Abdominal Trauma:

Abdominal injury may result in significant morbidity and mortality. The most commonly injured organs are the spleen (over 60%), liver, pancreas, kidneys, and, less frequently, small bowel and bladder.[13] Overt findings may not always be present. Rapid screening, such as the Focused Assessment with Sonography for Trauma (FAST), may assist in evaluating for acute injury along with laboratory tests including amylase, lipase, liver function tests, and urinalysis. Any positive ultrasound or laboratory finding suggests the need for further workup or imaging, such as an abdominal and pelvic CT scan.

Bites

Human bites are a “2 to 5 cm oval or circular mark, made by two opposing concave arcs, with or without associated ecchymosis”.[14] Bitemarks can provide useful evidence in cases of physical assault of a child and can also be a source of the assailant’s DNA. Measurement of the inter-canine distance of the bite may help distinguish between an adult's bite (3.0 to 4.5 cm), a small adult’s bite (2.5 to 3.0 cm), or a child’s bite (2.5 cm, child's deciduous teeth). However, the data is not validated in clinical practice.

Bruising

A bruise is the most common soft tissue injury in cases of physical abuse. Bruises can be characterized as:

• Petechiae: very small, pinpoint erythematous, non-blanching bruises caused by broken capillaries.
• Purpura: small bruises occurring in groups or a single bruise up to 1 cm
• Ecchymoses: larger bruise > 1 cm. 

Bruising in non-abused children is most commonly found on the knees, shins, and bony prominences. Bruising in non-ambulatory children is uncommon and is concerning for non-accidental trauma. Commonly in abuse, bruises will be found on the backside of the child, beginning at the neck and continuing down to the knees, including shoulders and the child's arms. This area has been referred to as the child's "primary target zone." The following pattern of bruises are potentially worrisome:

• Clustered or patterned
• Inconsistent with history
• Large or numerous
• Present in various stages of healing
• Present in non-ambulatory children[15] 

A pediatrician needs to differentiate bruises from “pseudo-bruises" such as Mongolian spots (grey-blue, can be found anywhere on the body and have clear cut margins), maculae cerulae (bluish spot on the skin due to pubic lice), and allergic shiners (more brown than blue, may be confused with black eyes). Also on the differential diagnosis for bruises are bleeding disorders, vasculitides, hypersensitivity syndromes, and various cultural practices such as spooning, coining, and cupping. 

Burns

Burns are often accidental and can lead to significant morbidity and mortality in children. Burns that cannot be explained by history, present with a significant delay in seeking care, have characteristic sharp lines of demarcation (also called the line of immersion), or have a symmetric pattern are concerning for child abuse. Other typical burns for child abuse include:

• Immersion burns: doughnut burns (as buttocks make firm contact with the base of a container) or zebra burns (a child immersed in a flexed position with spare the creases of child’s body giving a striped configuration)
• Glove-like or sock-like burns from immersion of child’s feet and hands
• Dry contact burns patterned like a household appliance, such as an iron, stove, heater, grate, radiator pipe, hot plate, or curling iron.
• Round cigarette burns
• Rope burns

The differential diagnosis of burns includes:

• Chemical and irritants: bleach, complementary and alternative therapies
• Infection: impetigo, blistering distal dactylitis, ringworm
• Stephens-Johnson Syndrome or toxic epidermal necrolysis
• Dermatological conditions: diaper dermatitis
• Scalded skin syndrome

Lacerations

Lacerations are a pattern of injury in which skin and the underlying tissues are cut or torn. Unexplained lacerations in the following areas are potentially concerning:

• Arms, eyes, genitalia, gums, legs, lips, mouth, and torso

Behavioral Signs of Physical Abuse 

In addition to the history and physical examination, observation of the child's behavior, and the child-caregiver interactions during the encounter can provide clues to the potential for physical abuse.

Behavioral indicators of abuse in children include:

• Aggressive, destructive, or disruptive behavior
• Apprehensive when other children cry
• Compulsions, hypochondria, phobias, and obsessions
• Fear of going home
• Fear of caregiver
• Emotionless, passive, or withdrawn
• Habit disorders
• Lack of interest in activities for age
• Overly seeks affection
• Self-injurious behaviors
• Suicide attempts
• Return of bedwetting
• Unexpected sexual knowledge for age
• Unwilling to change clothes for physical education or sports
• Wearing concealing clothing

Behavioral indicators of abuse in caregiver include:

• Alcohol or drug abuse
• Concealment of injuries
• Disciplines harshly
• Describes child as evil
• Delays medical care
• History of abuse as a child
• Lack of emotional control
• Lack of parenting skills
• Lack of support network
• Multiple providers
• Overly protective or jealous
• Poor self-esteem
• Unconcerned about child's health or well-being
• Unclear or conflicting explanation of the child's injury
• Uses the child to meet emotional or physical needs
• Unrealistic expectations

Sexual Abuse 

Sexual behaviors are rare in infants except for hand to genital contact. They become more prevalent in children 2-5 years of age as they become aware of their body parts, and then they become less common > 5 years as children become aware of social rules. However, if a child has inappropriate behaviors such as an older child touching other children's genitals, undressing in front of others, and looking at others undressing, there should be a concern.

Sexual abuse involves the coercion of a dependent, developmentally immature person to commit a sexual act with someone older, sometimes for financial gain (i.e., sex trafficking).[10][16][17][18]

A normal physical examination does not rule out sexual abuse, and the most common finding in sexual abuse is a normal physical examination. In most cases, evidence that sexual abuse has occurred is based on the child's statement. Suspicion should be raised if any of the following are present:

• Alcohol and drug addiction
• Adolescent pregnancy
• Agoraphobia
• Alopecia areas
• Anogenital trauma
• Anxiety
• Bruises
• Burns
• Bloody or torn underwear
• Bruises on the palate
• Depression and suicidal thoughts
• Diseases that are untreated or not diagnosed
• Fractures
• Head injuries
• Lacerations
• Ligature injuries
• Malnourishment
• Painful urination and bowel movements
• Painful sitting or walking
• Panic attacks
• Poor hygiene
• PTSD
• Recurrent urinary tract infections
• Sexually transmitted diseases and pelvic infections

Epidemiology

It may be a challenge to recognize sexual abuse as physical evidence may be overlooked or not present. Considerations include: [16][17][18]

• Every culture, class, and race is at risk.
• Boys are less likely to report their victimization.
• Children may be reluctant to disclose abuse by a family member or friend.
• A young child may not have the language skills to describe events.
• Girls are sexually abused more often than boys.
• Perpetrators are more commonly male.
• Most perpetrators are known to the victim.

There is no average profile of a child molester or victim; any community member may be an offender.

Long-term effects of sexual abuse include:

• Anxiety
• Difficulty concentrating
• Depression
• Self-injurious behaviors
• Substance abuse
• Suicide

Sex Trafficking 

The Trafficking Victims Protection Act defines "severe forms of trafficking in persons" as (a) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion, or in which the person induced to perform such an act has not attained 18 years of age; or (b) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. Commercial sex act means any sex act on account of which anything of value is given to or received by any person.[10][19] Considerations include:

• The average age is of sex trafficking victims is 11 to 14 years.
• Frequently starts on the internet.
• The number of victims worldwide is in the millions, and half of the affected individuals are children.
• Women more commonly affected than men

Screening Questions

If sex trafficking is suspected, complete the physical examination in private, then consider the screening questions in the figure.[10][19][16][17][18]

Neglect

Physical examination may not only demonstrate signs of physical abuse but may show signs of neglect. The general examination may show poor oral hygiene with extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds.

Indicators of physical neglect include:[5]

• Abandonment
• Drug withdrawal symptoms
• Delayed development
• Failure to thrive
• Hunger
• Inappropriate dressing
• Lack of supervision
• Poor hygiene 
• Truancy
• Unattended physical problems

Emotional Neglect

Behavioral indicators of neglect in a child include:

• Alcohol or substance abuse
• Begging or stealing food
• Chronic fatigue
• Conduct disorders and delinquency
• Developmental delay
• Extended stays at school
• Habit disorders
• Hysteria
• Hypochondria
• Inhibition of play
• Absence of caretaker at home
• Obsessive-compulsive behaviors
• Overly compliant
• Overly demanding
• Passive-aggressive
• Phobias
• Runaway
• Sleep disorders
• Suicide attempt

Behavioral indicators of neglect in a legally responsible person include:

• Blaming the child for problems
• Inconsistent treatment
• Lack of caring
• Continued rejection
• Treating children unequally

Mandated Reporters:

All healthcare providers are mandated reporters, and, as such, they are required to make a report to child welfare when there is a reasonable suspicion of abuse or neglect. One does not need to be certain, but one does need to have a reasonable suspicion of the abuse. This mandated report may be lifesaving for many children. An interprofessional approach to the evaluation with the inclusion of a child-abuse specialist is optimal.

Forensic Evidence

If child abuse or neglect is considered, the history and physical examination findings may be used in legal proceedings. Photographs, diagrams, and detailed findings are helpful for recall at trial. Findings should be reported accurately and without bias. [16][17][18]

Photographs

New York Social Service Law allows any person or official required to take evidence for suspected abuse to take color photographs of visible trauma or radiographs. The images should be provided to Child Protective Services as soon as possible. Consent is not needed for a minor child to be photographed if child abuse is suspected and reported to the Statewide Central Register. A chain of custody should be maintained. The institutional protocol for releasing photographs should be followed.

Tips for taking photographs:

• Include the child's name, date of birth, medical record number, date and time of photographs, and name of the provider on an index card
• Take photos at various ranges: distant, mid-range, and close up.
• Use adequate lighting
• Include anatomic landmarks to identify the location of findings.
• Use a ruler placed on the skin to document the size of any findings.
• The child's face and body should be photographed for identification of the patient.

Victim Disclosures

If a child discloses abuse, they may only disclose part of what happened. Document in the child's own words and quote the child if possible. Avoid rushing the child or making promises you cannot keep. Explain to the child they may need to repeat the information. Methods to enhance disclosure include:[16][17][18]

• Ask who, what, where, and when
• Ask open-ended questions
• Avoid expressing emotion
• Be a good listener
• Remain calm
• Thank them for talking to you
• Use age-appropriate language

Indirect Hints

• Admitting to a problem but being unwilling to share
• My father, mother, brother, or sister would not let me sleep.
• My uncle, aunt, cousin, babysitter keeps bothering me.

Factitious Disorder[20][21] 

Factitious disorder imposed on another or Munchausen syndrome by proxy is a form of child abuse. It typically occurs when a caretaker falsifies an illness in the child to gain attention. There generally are no obvious external monetary rewards. 

Typical findings in factitious disorder include:[16][17][18]

• Deceptive behavior is evident in the absence of obvious external rewards.
• Falsification of physical or psychological signs or symptoms
• History of many hospitalizations with unusual signs and symptoms
• History of unusual death or illness in the family
• Improves when hospitalized but worsens when returns home
• Lab samples do not match the child.
• Not better explained by another mental disorder.
• Presents another individual to others as ill, impaired, or injured
• Signs and symptoms do not agree with the test results.
• Toxic or abnormal chemicals in the child's blood, stool, or urine
• Worsening of the child's symptoms by the perpetrator but not witnessed by healthcare professionals

Evaluation

Laboratory Tests

Laboratory evaluation may be performed to evaluate for other diseases as the causes of the injury. These laboratory tests can include:

• CBC: to evaluate for anemia and thrombocytopenia
• Coagulation profile: PT/INR, PTT
• Metabolic: glucose, BUN, creatinine, albumin, protein
• Liver: AST, ALT
• Pancreas: amylase, lipase
• Bleeding diatheses: von Willebrand antigen, von Willebrand activity, Factor VIII, Factor IX, and platelet function assays
• Bony disorders: calcium, magnesium, phosphate, alkaline phosphatase

Radiology

Any child < 2 years of age for whom there is a concern regarding physical abuse should have a complete skeletal survey obtained as part of the evaluation. Additionally, any sibling < 2 years of an abused child should also have a skeletal survey performed. A skeletal survey consists of 21 dedicated X-rays, as recommended by the American College of Radiology. The views include the skull, spine, chest/ribs, pelvis, femur, leg, foot, humerus, forearm, and hand. If the findings are abnormal or equivocal, either further dedicated X-rays of the area of concern and/or follow-up X-rays are indicated in 2 weeks to evaluate for healing fractures. 

One should consider that the most common differential diagnosis of non-accidental injury is an accidental injury.[22][23][24][1][5]

Treatment / Management

Initial management of an abused child involves stabilization, including assessing the patient's airway, breathing, and circulation. Once ensured that the patient is stable, a complete history and physical examination are required. With the suspicion for any form of child abuse, CPS needs to be informed. The involvement of a child abuse specialist is important for optimal evaluation and management. If the patient is seen in an outpatient setting, transfer to an emergency department for laboratory and/or radiologic evaluation, and the appropriate continuation of care may be indicated. If a child is transferred to another physician or facility, the initial physician caring for the patient has the responsibility of reporting the case to CPS. It is the responsibility of the physician to recognize potential abuse, not to identify the perpetrator. The physician should continue to advocate for the child, ensuring that the patient receives the appropriate follow-up care and services.

Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed, and empiric treatment for HIV, gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection for the adolescent victims should be offered. Also, emergency contraception to prevent unwanted pregnancy is most effective if given within 72 hours but may be offered up to 5 days after unprotected intercourse. Prepubertal patients are not provided with prophylactic treatment due to the low incidence of STIs in this age group. Urgent evaluation can prove extremely beneficial for patients needing prophylactic STI treatment, emergency contraception, managing anogenital injury, collecting forensic evidence, urgent child protection, or urgent care for suicidal ideation.[25][26][27][1][5][10](B3)

Differential Diagnosis

The differential diagnosis for abuse depends on age, injury type, and signs and symptoms. The differential diagnosis of injury usually differentiates between accidental and inflicted trauma. An astute healthcare provider must carefully consider organic disease processes or accidental injury versus deliberately inflicted trauma.

• Accidental asphyxia[28]
• Accidental bruises 
• Accidental fractures 
• Accidental burns
• Accidental head injury 
• Arteriovenous malformations 
• Atopic dermatitis[29]
• Bleeding or hemorrhagic disorder[30][31]
• Birth trauma[32]
• Caffey disease[33]
• Chemical burn[34]
• Coining[35]
• Congenital syphilis[36]
• Contact dermatitis
• Cupping[35]
• Erythema multiforme[37]
• Factitious disorder
• Hemangioma[38]
• Henoch-Schönlein purpura[39]
• Hypervitaminosis A[40]
• Immune thrombocytopenic purpura[40]
• Impetigo[41]
• Inflammatory skin conditions 
• Insect bites[42]
• Osteogenesis imperfecta[43]
• Osteomyelitis[44]
• Osteopenia
• Malignancy
• Meningitis[45]
• Menkes disease[46]
• Metabolic disease
• Mongolian spots[47]
• Nevi[48]
• Phytophotodermatitis[49]
• Rickets[50]
• Scurvy[51]
• Sunburn[52]
• Valsalva induced subconjunctival hemorrhage[53]

Complications

• Fractures
• Burns
• Disfigurement
• Emotional trauma
• Seizures
• Mental retardation
• PTSD