Chapter 12 Child Abuse and Neglect
PATHOPHYSIOLOGY
The Federal Child Abuse Prevention and Treatment Act, as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect as, at a minimum, “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.” There are four major types of abuse: physical abuse, sexual abuse, emotional abuse (psychologic, verbal, or mental injury), and child neglect. It is of interest to note that emotional abuse is almost always present when other forms are identified. The most recent research suggests several other types or subcategories of maltreatment, including congenital child abuse, sibling abuse, and child abandonment.
Child maltreatment crosses all areas of society and all cultural, racial or ethnic, religious, socioeconomic, and professional groups. It is most common, however, among adolescent parents and in low-income families. Risk factors and statistics associated with child maltreatment are categorized as they relate to parents, children, families, and the environment.
Perpetrators of child maltreatment are the persons responsible for a child’s well-being, such as parents or caretakers, who have abused or neglected the child. Maltreating parents consistently report having been physically, sexually, or emotionally abused or neglected as children. However, not all maltreated children grow up to be abusive parents. Approximately 80% of perpetrators are parents. Other relatives account for 6%, and unmarried partners of parents account for 4% of perpetrators. The remaining perpetrators include persons with other relationships (e.g., camp counselor, school employee) or unknown relationships to the child victims. Common characteristics identified in abusive parents include low self-esteem, low intelligence, social isolation, depression, low frustration tolerance, immaturity, lack of parenting and/or coping skills, lack of knowledge of child development, marital problems, single or adolescent parenthood, closely spaced pregnancies, substance abuse, physical illness, and criminal behavior.
A number of characteristics have been associated with children who are victims of abuse. Children at greater risk for abuse are those who are born prematurely and/or with congenital anomalies or who have difficult-to-soothe temperaments, frequent illness, or special needs. Children from birth to 3 years of age are at highest risk for physical abuse. Girls are slightly more likely to be victims than boys (52% to 48% of victims). Children are consistently vulnerable to sexual abuse from age 3 years and up. More recently, public attention has been directed to recognizing the vulnerabilities that youth may encounter with adult sexual predators through the Internet and from adult authority figures in schools, social organizations, and even religious institutions. Pacific Islander, American Indian, Alaska Native, and African-American children have the highest rate of victimization according to the national population.
Some known characteristics are associated with families at high risk for abusing children. Children in single-parent families had a 77% higher risk of physical abuse, an 87% higher risk of physical neglect, and an 80% higher risk of serious injury or harm from abuse or neglect than children living with both parents. Children in the largest families were physically neglected nearly 3 times more often than those from single-child families. Children from families with annual incomes below $15,000 were more than 22 times more likely to suffer some form of maltreatment as defined by the Harm Standard and more than 25 times more likely to experience some form of maltreatment as defined by the Endangerment Standard than were children from families with annual incomes above $30,000. Harm Standard refers to child maltreatment as identification of children who have experienced observable harm; endangerment standard refers to child maltreatment as identification of children based on risk for being harmed.
Children from the lowest-income families were 18 times more likely to be sexually abused, almost 56 times more likely to be educationally neglected, and over 22 times more likely to suffer serious injury as defined by the Harm Standard than were children from higher-income families. Children living in the same home for less than 2 years and living in the same community less than 5 years have a 60% higher risk of being abused.
Environmental factors related to child abuse include ethnic and/or racial prejudices, poor living conditions, lack of community and family resources, poor access to health care and follow-up services, economic pressure, varied cultural beliefs concerning the role of the child in the family, and varied cultural attitudes toward use of physical punishment. Ineffective child protection laws are another culprit in the environment. Studies have shown that nearly half of the children killed by caretakers are killed after they come to the attention of the child welfare service. Keeping the family intact may no longer be the goal if maltreatment is significant.
INCIDENCE
1. In 2003, child protective services investigated more than 2.9 million reports alleging maltreatment of more than 5.5 million children.
2. Two thirds (68%) of these reports prompted investigations, which resulted in the identification of 906,000 victims.
3. An estimated 1500 child maltreatment fatalities occurred in the 50 states and the District of Columbia in 2003. Children younger than 1 year of age accounted for 44% of all deaths, and 79% of child fatalities were in children younger than 4 years of age.
4. More than half of all victims (60%) suffered neglect (including medical neglect), 20% suffered physical abuse, and about 10% of victims were sexually abused. Victims of emotional maltreatment accounted for 5% of all victims. Other types of maltreatment including abandonment, congenital drug addiction, and threats to harm the child accounted for 16% of victims. (Percentage totals are higher than 100% because some children suffered multiple types of abuse.)
5. Sexual abuse is most common among girls, stepfamilies, and children living with one parent or a primary caregiver who is an unrelated male.
6. Abuse occurs in 11 per 1000 white, 21 per 1000 Pacific Islander, 21 per 1000 American Indian and Native Alaskan, and 20 per 1000 African-American children.
CLINICAL MANIFESTATIONS
See Box 12-1 for a list of the clinical manifestations of child abuse.
Box 12-1 Clinical Manifestations of Child Abuse and Neglect
Skin Injuries
Skin injuries are the most common and easily recognized signs of maltreatment in children. Human bite marks appear as ovoid areas with tooth imprints, suck marks, or tongue-thrust marks. Multiple bruises or bruises in inaccessible places are indications that the child has been abused. Bruises in different stages of healing may indicate repeated trauma. Bruises that take the shape of a recognizable object are generally not accidental.
Traumatic Hair Loss
Traumatic hair loss occurs when the child’s hair is pulled or used to drag or jerk the child. The result of the pulling on the scalp can cause the blood vessels under the skin to break. An accumulation of blood can help differentiate between abusive and nonabusive loss of hair.
Falls
If a child is reported to have had a routine fall but has what appear to be severe injuries, the inconsistency of the history with the trauma sustained raises the suspicion of child abuse.
External Head, Facial, and Oral Injuries
Cuts, bleeding, redness, or swelling of the external ear canal; facial fractures; tears or scarring of the lip; oral, perioral and/or pharyngeal lesions; loosened, discolored, or fractured teeth; dental caries; tongue lacerations; unexplained erythema or petechiae of the palate; and bilateral black eyes without trauma to the nose all may indicate abuse.
Deliberate or Unexplained Thermal Injuries
The following suggest intentional harm: immersion burns, with clear line of demarcation; multiple small, circular burns, in varying stages of healing; iron burns (show iron pattern); diaper area burns; and rope burns.
Shaken Baby Syndrome
A shaken baby may suffer only mild ocular or cerebral trauma. The infant may have a history of poor feeding, vomiting, lethargy, and/or irritability that occurs periodically for days or weeks before the initial health care consultation. In 75% to 90% of cases, unilateral or bilateral retinal hemorrhages are present, but they may be missed unless the child is examined by a pediatric ophthalmologist. Shaking produces an acceleration-deceleration (shearing) injury to the brain, causing stretching and breaking of blood vessels that results in subdural hemorrhage. Subdural hemorrhage may be most prominent in the interhemispheric fissure. However, cerebral edema may be the only finding. Serious insult to the central nervous system may result, without external evidence of injury.
Unexplained Fractures and Dislocations
Posterior rib fractures in different stages of healing, spiral fractures, or dislocation from twisting of an extremity may provide evidence of nonaccidental injury in children.
Sexual Abuse
Abrasions or bruising of the inner thighs and genitalia; scarring, tearing, or distortion of the labia and/or hymen; anal lacerations or dilation; lacerations or irritation of external genitalia; repeated urinary tract infections; sexually transmitted disease; nonspecific vaginitis; pregnancy in the young adolescent; penile discharge; and sexual promiscuity may provide evidence of sexual abuse.
Neglect
The symptoms of neglect reflect a lack of both physical and medical care. Manifestations include failure to thrive without a medical explanation, multiple cat or dog bites and scratches, feces and dirt in the skin folds, severe diaper rash with the presence of ammonia burns, feeding disorders, and developmental delays.
COMPLICATIONS
1. Developmental and neurologic: attention-deficit/hyperactivity disorder (ADHD), developmental delays
2. Academic: learning difficulties and low academic achievement
3. Mental health: aggressive behaviors (fighting or cruelty to animals), substance abuse, other mental health problems (e.g., depression, post-traumatic stress disorder, eating disorders), suicide attempts
4. Psychosocial: difficulties with social relationships, developmental delays, inappropriate sexual behaviors and teen pregnancy, increased risk for sexually transmitted diseases (e.g., acquired immunodeficiency syndrome [AIDS])
LABORATORY AND DIAGNOSTIC TESTS
1. Skeletal (bone) survey radiographic studies, in two planes, for all children with suspected abuse injuries. Repeat in 2 weeks for children for whom there is a strong suspicion of abuse—RATIONALE: metaphyseal (“corner-chip”) fractures have high specificity for abuse but may be difficult to see initially. Healing fractures form a callus (bump of bone) that is apparent within 2 weeks of an acute injury. Skeletal surveys also provide information about the age of the injuries. Multiple fractures at various stages of healing are common in child abuse
2. Computed tomography and/or magnetic resonance imaging of affected areas—to verify presence of injuries
3. Ophthalmologic examination—to detect retinal hemorrhages (result from severe shaking or slamming of head)
4. Color photographs of injuries—for legal and clinical documentation
5. Head circumference, abdominal circumference—to determine skeletal and/or abdominal injuries due to physical abuse
6. Examination of cerebrospinal fluid—to detect presence of blood in children who sustained head trauma from physical abuse
7. Pregnancy test—to determine pregnancy status in children who have been sexually abused
8. Screens for sexually transmitted infections (STIs), human immunodeficiency virus (HIV)—to detect STIs in children who have been sexually abused
9. Evidentiary examination—to collect specimens and reveal signs and symptoms of abuse (should comply with the recommendations of child protective services or local coroner or medical examiner)
MEDICAL MANAGEMENT
The first priority in the care of the abused child is resuscitation and stabilization as deemed necessary according to the injuries sustained. Confirmation of the abuse is achieved through thorough history taking, complete physical examination with detailed inspection of the child’s entire body, and collection of laboratory specimens. All injuries should be documented with color photographs and recorded carefully in the written medical record.
Every state has a child abuse law that specifies legal responsibilities for reporting suspected abuse. Suspected abuse must be reported to the local child protective service agency. Mandated reporters include nurses, physicians, dentists, podiatrists, psychologists, speech pathologists, coroners, medical examiners, child day care center employees, children’s services workers, social workers, clergy, film and photographic print processors, law enforcement officers, and schoolteachers. Failure to report suspected child abuse can result in a fine or other punishment, depending on individual statutes.
NURSING ASSESSMENT
1. Conduct comprehensive history taking and parent (or caregiver) interview. Verification and documentation of circumstances associated with the injury event are critical. Therefore nurse should make a written checklist of who, what, when, where, why, and how questions and answers.
2. Perform comprehensive physical examination as well as social, emotional, and cognitive assessment.
3. Observe parent-child interactions, including frequency of contact and length of time parent visits child.
4. Assess emotional status of parents.
5. If a child is initially seen in the emergency room and a sexual assault is suspected, a sexual assault nurse examiner may be contacted to conduct the examination (Box 12-2).
NURSING INTERVENTIONS
1. Resuscitate and stabilize as necessary.
2. Protect child from further injury.
3. Assist with diagnosis of abuse.
5. Provide supportive care to child (refer to supportive care section in Appendix F).
6. Document assessment of physical findings, parent interactions, and child’s verbal disclosures.
7. Provide explanations of normal child growth and development, and compliment parent for behaviors that indicate appropriate responses to child’s needs (refer to Appendix B).
8. Discuss, encourage, and role-model behaviors that foster maternal-child attachment and positive parenting skills.
9. Discuss alternative methods of discipline, and encourage positive reinforcement for good behavior in child.
10. Discuss family stress and review coping strategies (positive versus negative).
11. Discuss need for community resources and make appropriate referrals (e.g., child life specialist; child protective services; social worker; home visiting nurse; parenting classes; women, infants, and children [WIC] services; fuel assistance; Section 8 housing assistance; Parents Anonymous; Parents United International) (refer to Appendix G).
Discharge Planning and Home Care
1. Refer parents to multidisciplinary community resources that will assist with improving impulse control, increase knowledge of child’s growth and development, aid in setting realistic expectations, and provide alternatives to physical abuse (Box 12-3).
2. Refer family to support groups, family therapy, or parenting effectiveness classes.
Child Welfare Information Gateway. Child abuse and neglect information packet, 2006. www.childwelfare.gov/pubs/can_info_packet.pdf, 2006 (website): Accessed March 22, 2007
Flaherty EG, et al. Assessment of suspicion of abuse in the primary care setting. Ambul Pediatr. 2002;2:120.
International Child Abuse Network:. Child abuse statistics, 2006. (website): www.yesican.org/stats.html Accessed December 28
Oliver WJ, Kuhns LR, Pomeranz ES. Family structure and child abuse. Clin Pediatr. 2006;45(2):111.
U.S. Department of Health and Human Services. Children’s Bureau, Administration for Children and Families. Child maltreatment 2003, 2006. (website): http://acf.hhs.gov/programs/cb/pubs/cm03/index.htm Accessed April 25
