Child Abuse and Neglect

Etiology

Although child abuse is not classified as a disease, its etiology can be better understood by identifying various risk factors and underlying contributing conditions. Most parents genuinely want what's best for their children, including those caregivers who engage in abusive behaviors. The question remains: Why do adults abuse children who are dependent upon their care?

Risk factors for child abuse and neglect can be categorized into factors related to the child, caregiver, household environment, and broader community. Children born from unplanned or unwanted pregnancies or those with a history of preterm birth, physical disabilities, chronic illness, or behavioral difficulties are more vulnerable to neglect and abuse.[6]

Caregivers with substance use disorders, mental illness, or those who have experienced abuse themselves are more likely to become abusers compared to the general population.[7] Additional risk factors include young parental age, poor impulse control, low educational attainment, unrealistic expectations that don't align with the child's age and developmental stage, and a criminal history.[2] Abused children more often reside in home environments with multiple children, single parents, or non-biologically related adults. The presence of domestic violence and previous involvement with Child Protective Services (CPS) also increases the likelihood of abuse or neglect.

Additional community risk factors include poverty, social isolation, high rates of violent crime, lack of safe childcare, and cultural norms that condone harsh disciplinary measures such as excessive corporal punishment.[7] These factors can create an environment where abuse is more likely to occur and less likely to be reported or addressed effectively.

Protective factors that can reduce the risk of child abuse include nurturing relationships between children and caregivers, parental knowledge of child development and positive discipline strategies, involvement of extended family, safe neighborhoods, affordable housing and childcare, and access to healthcare, social services, and substance use disorder treatment.[8] These factors foster a supportive environment that promotes the well-being of children and helps mitigate the risk of abuse.

The etiology of child abuse involves a complex interplay of individual, familial, and environmental factors, including children with behavior and health concerns, parental mental health or substance use disorders, socioeconomic disadvantages, a history of abuse, unsafe neighborhoods, and a lack of community support for families.[9] Identifying and addressing these risk factors at both the individual and population levels is crucial for prevention, early diagnosis, and effective interventions for vulnerable children at risk of or affected by abuse.

Epidemiology

Child abuse affects individuals of all races, ethnicities, and socioeconomic backgrounds, with boys and adolescents being more commonly affected by physical abuse than girls and younger children. However, infants and toddlers experience higher rates of morbidity and mortality due to physical abuse and neglect. The incidence of child abuse varies significantly across countries and regions, likely influenced by cultural, socioeconomic, and reporting differences.

In the United States, approximately 4 million children are reported to CPS annually due to concerns of abuse or neglect, with evidence of maltreatment confirmed in nearly 20% of cases. The exact number of occurrences is difficult to determine due to inconsistent reporting and the likely underdetection of many instances of maltreatment.[6]

Approximately 12.5% of children in the United States will experience a confirmed case of maltreatment by the age of 18. Rates are slightly higher for girls (13.0%) than for boys (12.0%), primarily due to girls being more frequently victims of sexual abuse. Racial disparities are significant, with Black children experiencing a prevalence of 20.9%, Native American children 14.5%, Hispanic children 13.0%, White children 10.7%, and Asian or Pacific Islander children 3.8%.[10] 

An estimated 1570 children died from maltreatment in 2011, with the highest fatality rates among those aged 4 or younger.[11] The incidence of child maltreatment varies by region and state. Literature reviews on whether maltreatment rates are higher in rural or urban areas yield mixed results. Some studies report higher rates in rural areas, while others find greater prevalence in urban areas. Overall, the child maltreatment incidence tends to be higher in cities among people of color and higher in rural areas among White people.[12][13]

Studies indicate that Black, Indigenous, and multiracial children are reported to CPS and undergo investigations and interventions more frequently than White children, even when the severity of abuse is comparable.[14] Research suggests that racial and ethnic disparities in CPS involvement may stem from systemic factors, including differences in reporting patterns, socioeconomic conditions, and structural inequities.

Factors such as poverty, limited access to quality healthcare and education, and an increased risk of family instability in marginalized communities may contribute to higher CPS involvement.[15] Additionally, studies have found that children from racial and ethnic minority groups are more likely to have their cases substantiated or experience out-of-home placements, raising concerns about potential bias within the reporting and intervention processes.[16] These disparities highlight the need for continued examination of systemic influences on child welfare outcomes.

History and Physical

Obtaining a comprehensive history and conducting a thorough physical examination are critical first steps in evaluating potential child maltreatment. This process may be challenging, as some victims may not disclose abuse, and perpetrators or witnesses seldom provide accurate accounts. Some children may be unable to verbalize their experiences due to fear, severe injury, or developmental limitations. Others may disclose a history of abuse privately, while some children may present with unrelated medical concerns, with clinical findings prompting the healthcare team to suspect possible maltreatment. 

The American Academy of Family Physicians recommends a trauma-informed approach to care and the use of the pediatric Hurt-Insult-Threaten-Scream (HITS) screening tool to identify child abuse victims.[2] A thorough history and physical examination require a thoughtful approach to gather relevant behavioral and historical information. Clinicians should interview caregivers and children separately and carefully assess injuries to ensure an unbiased and comprehensive understanding of the situation.[2] 

When possible, clinicians should first review the medical record to gather as much information as possible, minimizing the risk of re-victimizing children by asking them to repeat their story multiple times. Verbal children often provide more details when their caregiver is absent from the examination room.[2] Asking open-ended, nonjudgmental questions while allowing patients and caregivers to speak without interruption often yields the most accurate and relevant information. In some cases, perpetrators may bring the child for medical attention due to concern over the severity of injuries, but may hesitate to provide a reliable account of the events. Other adults or mandated reporters may accompany the child, and clinicians should document the presence and role of these non-family members. A chaperone, such as a nurse or medical assistant, can help validate the clinician’s documentation and address potential challenges from families or legal representatives in the future.

The history should begin with assessing the child's behavior, symptoms, and the circumstances surrounding any reported injuries. Abused children, especially infants who have suffered inflicted head trauma, may present with nonspecific signs and symptoms, such as vomiting or apnea. "Red flags" include caregivers who provide vague, inconsistent accounts or change their stories over time. For example, falls from less than 5 feet generally do not cause severe neurological injuries, so a report of an infant "falling off the sofa" would be inconsistent with a serious head injury. Considering the child’s developmental stage is also crucial. For instance, an infant aged 3 months or younger is unlikely to roll over on a flat surface, and those aged 8 months or younger rarely have the motor skills to pull themselves to a standing position and then fall.[17] Additionally, an unexplained delay in seeking care for an injured child may raise suspicion of abuse, as it could suggest a lack of concern or an attempt to conceal an inflicted injury.

Understanding the pregnancy and birth history is also essential. Was the pregnancy planned or welcomed? Were there gestational or delivery complications, such as preterm birth or conditions resulting in disabilities? After reviewing the medical and surgical history, obtaining a developmental and behavioral history, including the child’s abilities, temperament, and any school-related issues, can offer valuable insights. A thorough social history should address family stressors, disciplinary practices, prior law enforcement or CPS involvement, and other social determinants of health. Relevant family history should include any genetic, hematologic, metabolic, bone, or substance use disorders.[2][17] After stabilizing the injured patient, the next step involves a thorough physical examination. Significant findings can help reveal the nature of the trauma, as outlined below. Subtle injuries or signs of underlying medical conditions—such as those related to bruising or bone fragility—must not be overlooked.

Adopting a trauma-informed care approach, clinicians should first ask verbal children if they feel anxious about the exam and inquire how the medical team can help them feel more at ease. Drapes and appropriately sized gowns should be used to maintain privacy, and chaperones should be present. Clinicians must obtain consent from verbal children before proceeding with potentially sensitive parts of the exam and should avoid repeating anogenital exams to prevent re-traumatization.[2] Clinicians must document their findings in detail, including body diagrams and forensic photographs when appropriate. They should be mindful that their medical records may be used in future legal proceedings. 

Bruising is the most common sign of physical abuse, but it is often overlooked as a sentinel injury. This sign is rare in nonambulatory children and should raise suspicion of abuse. In ambulatory children, the most common areas of accidental bruising are the knees, shins, and bony prominences such as the forehead. Bruising on the face, ears, neck, or torso, or multiple bruises that appear to be in different stages of healing, is concerning for inflicted trauma.

Various medical conditions, including osteogenesis imperfecta, Ehlers-Danlos Syndrome, thrombocytopenia, vitamin deficiencies, hemophilia, and leukemia, may cause bruising. A thorough physical examination may reveal relevant findings, such as blue sclerae in children with osteogenesis imperfecta. The "TEN 4" and the more comprehensive "TEN-4-FACESp" mnemonics highlight typical locations of inflicted bruises—Torso, Ears, and Neck in children aged 4 or younger, and any bruising in infants younger than 4 months. "FACES" refers to bruising of the frenulum, angle of the jaw, cheeks, eyelids, and subconjunctiva, while "p" stands for the pattern of injury, such as lesions with handprints or belt buckle impressions.[18] A careful skin inspection of the undressed child may reveal unreported bruises, which can be sentinel injuries indicative of maltreatment.[19] Noting the location and pattern of bruising is key in distinguishing abuse from accidental injury. Even children with inherited bleeding disorders rarely present with bruises in the "TEN-FACE" body areas.

Burns are a common form of both accidental and nonaccidental childhood injury. Scalding immersion burns, which often have sharp lines of demarcation, typically involve the genitals and lower extremities in a symmetric "stocking or glove" pattern, making them highly suspicious for abuse. Splash burns, on the other hand, are generally more likely to be accidental. For instance, an infant in a caregiver's lap might grab and overturn a hot beverage, or an older child could spill a bowl of microwaved soup. Accidental burns usually occur on exposed areas, such as the hands or arms, rather than in a symmetric distribution over covered body parts. Cigarette burns are usually inflicted and suggest deliberate harm, particularly when present in areas not typically exposed to accidental contact, such as the palms, soles of the feet, or genitals. The presence of multiple cigarette burns or burns in varying stages of healing may further indicate ongoing abuse.

Specific body parts to evaluate include performing a fundoscopic exam to check for retinal hemorrhages, assessing rib tenderness that may suggest fractures, and inspecting the skin for bruising and bite marks. The physical examination can reveal not only signs of intentional injury but also indicators of neglect, such as poor oral hygiene and extensive dental caries, malnutrition and growth failure, severe diaper dermatitis, or scars from untreated wounds.

Abusive head trauma (AHT), previously known as shaken baby syndrome, is the leading cause of severe head injury in infancy and the form of maltreatment with the highest mortality rate of approximately 20%.[19] The American Academy of Pediatrics recommended this change in terminology in a 2009 policy statement to better reflect the mechanisms that cause head injuries, including shaking, shaking with impact, and blunt impact alone. Most fatalities result from severe inertial brain injury, which causes acute subdural hemorrhage with brain swelling.[19] The more inclusive term AHT avoids suggesting that the exact nature of the injury is known in every case.[20]

Symptoms can range from subtle signs, such as vomiting, to more severe symptoms such as lethargy, seizures, apnea, or coma. Retinal hemorrhages, often observed during physical examination, are suggestive of abuse and should be confirmed by a pediatric ophthalmologist. Although trauma is the most common cause of retinal hemorrhages, some may be mistakenly attributed to cardiopulmonary resuscitation (CPR), despite CPR being an unlikely cause.[21]

Macrocephaly, a nonspecific finding, is observed in many infants with AHT. The occipital-frontal head circumference should be measured and compared to previous measurements from well-child visits. In some cases, macrocephaly may indicate previous or recurrent inflicted head trauma.[19] An infant with AHT who initially presents with minimal or no neurological findings may be misdiagnosed with acute gastroenteritis, otitis media, gastroesophageal reflux disease (GERD), colic, or other acute conditions, rather than being identified as a victim of child maltreatment.

In children with fractures, clinical signs may raise suspicion of abuse, particularly when the injury is inconsistent with the reported history or the child’s developmental abilities. Clinicians should assess for localized swelling and tenderness over bones, crepitus, refusal to move a limb, visible deformity or asymmetry of bony parts, and accompanying soft tissue injuries, such as burns or bruises. However, most children with fractures do not exhibit ecchymoses, and the presence or absence of bruising alone does not reliably differentiate between accidental and inflicted fractures.[22]

Abdominal trauma is a significant cause of morbidity and mortality in abused children and the second most common cause of death from nonaccidental trauma, primarily in infants and toddlers. Lesions can include lacerations or hematomas of the liver, splenic rupture, intestinal hematomas or perforation, pancreatic injury, retroperitoneal trauma (involving the kidneys and adrenals), and vascular tears. The physical examination may reveal abdominal distension, bruising, or tenderness, although some children may not show overt signs. Right upper quadrant tenderness suggests hepatic injury, such as lacerations, contusions, or hematomas, while left upper quadrant pain or Kehr sign (referred left shoulder pain) may indicate splenic rupture.[17]

A thorough history and physical examination are essential for identifying both evident and subtle signs of child maltreatment, including bruising patterns, burns, fractures, head trauma, and signs of neglect. Clinicians should adhere to trauma-informed care principles, meticulously document their findings, and remain vigilant for evidence of injuries inconsistent with the child's developmental abilities or the reported history.

Evaluation

After the initial history and physical examination, further evaluation of suspected child abuse involves comprehensive imaging and laboratory studies to detect occult injuries, differentiate inflicted trauma from medical conditions, and guide appropriate interventions. The choice of imaging depends on the child's age and presenting symptoms, with pediatric radiologists and child abuse pediatricians assisting in selecting the most appropriate studies.[22] In some cases, transferring the child to a higher level of care for specialized consultation may be prudent.[23]

Guidelines recommend imaging in several situations where maltreatment is suspected, including cases with significant fractures but no reported trauma, injury histories that do not align with the fracture type or required force, and instances where caregivers provide inconsistent or changing explanations. Additional indications include fractures in nonambulatory children, fractures associated with abuse (such as rib fractures), multiple fractures, fractures of varying ages suggesting separate traumatic events, non-orthopedic injuries concerning for abuse, and delays in seeking medical care for an injured child.[24]

Children aged 24 months or younger with fractures potentially caused by abuse should undergo a radiographic skeletal survey to identify additional orthopedic injuries or abnormalities. Skeletal surveys reveal unsuspected fractures in approximately 10% of cases, with the highest yield (13%-26%) in infants.[22] Skeletal surveys may be appropriate in children aged between 24 and 60 months, depending on the level of clinical suspicion. 

The American College of Radiology has established specific guidelines for performing skeletal surveys, emphasizing the need for an appropriately skilled radiology team and facility. The survey consists of 21 dedicated views, including anteroposterior (AP) and lateral views of the skull, lateral spine, AP, right posterior oblique, and left posterior oblique views of the chest/ribs, AP of the pelvis, femurs, legs, humeri, and forearms, as well as posterior and anterior views of the hands and AP of the feet.[22] The exact number of images may vary depending on the clinical situation and suspected injuries. If initial findings are abnormal or equivocal, a follow-up survey in 2 weeks is recommended to detect callus formation, additional fractures, and assist in dating injuries. Clinicians should also consider conducting skeletal studies of younger siblings of abused children, as they are at a higher risk for maltreatment than the general population.[24][25]

Targeted imaging should be performed, regardless of the child's age, when specific clinical findings suggest injury in a particular area. Long bone fractures, especially in nonambulatory children, are highly suspicious for abuse. The femur, humerus, and tibia are the most commonly injured long bones in cases of child abuse. While no fracture is pathognomonic for abuse, certain types are more suggestive than others. Posterior or lateral rib fractures, often caused by squeezing or direct chest blows, are highly concerning. Classic metaphyseal lesions, also known as "corner" or "bucket handle" fractures, occur at the junction of the diaphysis and the metaphysis of long bones and result from excessive shearing forces. Spiral fractures, which result from severe twisting forces, are uncommon in preambulatory children and should raise concern for inflicted injury. When standard radiographs fail to detect suspected fractures, nuclear bone scans can indicate occult fractures up to 2 weeks after the injury.[24] 

Chest computed tomography (CT) scans are useful for detecting rib fractures, including anterior rib fractures and those in various stages of healing, which may not be visible on standard chest radiographs. Rib fractures have a high predictive value for child abuse, with a 95% likelihood of abuse in children aged 3 or younger. Chest and abdominal CT with contrast are also valuable for detecting intrathoracic and intra-abdominal traumatic injuries.[26] The most common intra-abdominal injuries result from blunt forces, such as punching or kicking, leading to liver lacerations or contusions, intestinal perforation, and damage to the spleen, kidneys, or bladder. However, as CT scans expose children to higher radiation levels than standard x-rays, clinicians should consider using modified CT protocols with lower radiation doses when possible to minimize exposure.[25][27]

In cases of suspected AHT, a cranial CT without contrast or magnetic resonance imaging (MRI) can detect subarachnoid and subdural hemorrhages, as well as parenchymal injuries. Cranial ultrasonography is too insensitive for diagnosing AHT. Plain radiographs may reveal skull fractures, which occur in 25% to 40% of children with AHT. However, no specific type of skull fracture is pathognomonic for AHT.[19][28]

Clinicians should order laboratory tests to assess injuries and evaluate potential underlying medical conditions that may mimic abuse, identify metabolic or bleeding disorders, and detect additional occult injuries. The history and physical examination findings should guide the laboratory evaluation. In children with fractures suspected of being caused by abuse, serum calcium, phosphorus, and alkaline phosphatase levels may suggest underlying metabolic bone disorders, such as rickets or osteogenesis imperfecta. When radiologic evidence suggests metabolic bone disease or osteopenia, measuring serum parathyroid hormone and 25-hydroxyvitamin D levels may yield helpful diagnostic information.[22]

Children with abdominal trauma should undergo serum testing for amylase, lipase, and liver enzymes, along with a urinalysis to identify occult hematuria. Individuals with bruising or bleeding should undergo evaluation with a complete blood count, coagulation studies (prothrombin time, partial thromboplastin time, and international normalized ratio), and, if indicated, specialized tests for bleeding disorders such as Von Willebrand disease or hemophilia. In cases of abdominal blunt trauma, a fecal occult blood test may help detect gastrointestinal tract damage.[24] 

The evaluation of suspected child abuse involves a combination of imaging and laboratory studies to detect occult injuries, rule out medical conditions that mimic abuse, and guide clinical decision-making. Skeletal surveys are crucial in children under 24 months, as they can reveal additional injuries in up to 26% of cases. Chest and abdominal CT scans help identify rib fractures and internal injuries, while cranial CT or MRI is essential for diagnosing AHT. Laboratory tests assess underlying metabolic or bleeding disorders that may predispose children to fractures or bruising, ensuring a comprehensive approach to diagnosis and management.

Treatment / Management

The initial treatment of possible abuse victims begins with stabilization and management of acute medical concerns. Once the patient is stable, clinicians should perform a thorough history and physical examination before proceeding with diagnostic studies. Outpatients may require transfer to a hospital for a more comprehensive evaluation and specialized care. Many pediatric and teaching hospitals have child abuse pediatricians available to provide expert assessments in cases of suspected abuse and neglect.[29][30]

The clinician who first examines a child is a mandated reporter and must promptly notify CPS if there is any concern about possible child abuse. Although reporting protocols vary, this requirement applies in all 50 US states and many other countries. The role of the healthcare team is not to prove maltreatment or identify the perpetrator but to recognize children who may have experienced abuse. In some jurisdictions, healthcare providers are also required to report suspected abuse to local law enforcement authorities. 

The CPS team and social workers perform a thorough social evaluation, including an assessment of the home environment and the location of the reported injury. They determine whether the child can safely return home or needs alternative placement once hospital care is no longer necessary. CPS also evaluates siblings and other young household members, as research indicates they have approximately a 1 in 3 risk of experiencing maltreatment themselves. Twin siblings of abused children face an even higher risk.[31] CPS may recommend caregiver education and support services to help ensure a safe environment if the children are allowed to return home.

All victims of abuse should have their physical, mental, and psychosocial needs thoroughly addressed, with many benefiting from psychotherapy. Sexually abused adolescents require screening for sexually transmitted infections and pregnancy, as well as empiric treatment for HIV, gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis. Emergency contraception should be offered when appropriate. Trauma-informed care principles should guide all aspects of management, including forensic evidence collection, medical photography, and addressing acute psychological distress. Many hospitals utilize sexual assault nurse examiners (SANEs), who are specially trained in forensic evidence collection, trauma-informed care, and coordination with law enforcement and child protective services. These healthcare professionals play a crucial role in evaluating injuries, documenting findings, and offering expert testimony in legal proceedings when needed.[32]

Differential Diagnosis

The most critical aspect of the differential diagnosis is distinguishing child maltreatment from accidental trauma. A comprehensive medical history, physical examination, imaging studies, and laboratory results usually help determine whether an injury was inflicted or unintentional. In cases of accidental injury, caregivers typically provide clear and consistent accounts of the events leading to the injury. In contrast, changing or contradictory stories should alert clinicians to the possibility of abuse. 

Accidental bruises typically occur on the shins, knees, and forehead of ambulatory children. Ecchymosis in the "TEN-4-FACES" locations may indicate potential maltreatment, as can adult bite marks found anywhere on the body. Accidental animal bites typically show punctures and less evenly spaced marks than human bites. The number of tooth marks and bite size can help differentiate between a child's and an adult's bite, and consulting a dentist may assist in confirming the likely cause of the lesion. Medical conditions that lead to easy bruising include Henoch-Schonlein Purpura, idiopathic thrombocytopenic purpura, Ehlers-Danlos syndrome, hemophilia, pseudoxanthoma elasticum, leukemia, nutritional deficiencies, von Willebrand Disease, and other inherited coagulation disorders.[2]

Burns may result from accidental causes, such as splash burns, or intentional harm, such as immersion burns. Certain skin conditions, including Stevens-Johnson syndrome and toxic epidermal necrolysis, can mimic the appearance of burns. However, a detailed history and careful physical examination usually help differentiate true burns from other medical conditions.[2]

Birth trauma can result in fractures, and radiologic findings often assist in determining the timing of the injury. Although rare, certain medical conditions can predispose children to fractures, including congenital syphilis, leukemia, severe vitamin deficiencies, and osteogenesis imperfecta. The presence of blue sclerae on physical examination may suggest osteogenesis imperfecta.[2][22]

In cases of head injury, the event history typically helps differentiate between accidental and inflicted head trauma, with accidental injuries most often resulting from motor vehicle accidents or significant falls. Birth trauma is a relatively common cause of retinal hemorrhages, with approximately 85% resolving spontaneously within 14 days.[21] Rare causes of intracranial hemorrhage include bleeding disorders and intracranial vascular anomalies.[19]

Ultimately, a comprehensive assessment of the caregiver's account, the child's medical history, the characteristics of the injury, and imaging and laboratory findings is essential to determine whether the injury resulted from maltreatment, accidental trauma, or an underlying medical condition.

Prognosis

The prognosis for children who are victims of maltreatment is generally worse than for those with similar injuries resulting from accidental trauma, with higher mortality rates and longer hospital stays. Abused children often require more intensive medical interventions, including surgery.[17] Individuals with injuries involving multiple organs, such as abdominal trauma and AHT, face particularly high mortality risks.[33][34] Additionally, delayed presentation in abuse victims contributes to further complications and poorer outcomes.

Complications

Beyond acute injuries, child abuse can lead to lasting complications and long-term health conditions. Approximately 70% of survivors of AHT experience lifelong neurological impairments, including hemiplegia, quadriplegia, cognitive deficits, fine motor difficulties, visual impairment, and posttraumatic epilepsy.[19] 

Fractures may lead to permanent loss of limb function, and burns can result in lasting disfigurement. Some experts suggest that child maltreatment may contribute to the development of adult medical conditions such as fibromyalgia, irritable bowel syndrome, and obesity. Abused and neglected children are at higher risk of developing substance use disorders, suicidal ideation, and engaging in high-risk behaviors that increase the likelihood of sexually transmitted infections and unplanned pregnancies. Psychiatric sequelae can include anxiety, depression, and posttraumatic stress disorder.[2]