Office of Children and Family Services Child Abuse and Maltreatment Register

Child maltreatment is behavior toward a child that is outside the norms of conduct and entails substantial hazard of causing physical or emotional impairment. Four types of maltreatment are generally recognized: physical abuse, sexual abuse, emotional abuse (psychologic abuse), and neglect. The causes of kid maltreatment are varied and non completely understood. Abuse and fail are often associated with physical injuries, delayed growth and development, and mental problems. Diagnosis is based on history, physical exam, and sometimes laboratory tests and diagnostic imaging. Management includes documentation and treatment of whatever injuries and urgent physical and mental conditions, mandatory reporting to appropriate state agencies, and sometimes hospitalization and/or foster care to proceed the child safe.

In 2018, 4.3 meg reports of alleged kid maltreatment were made to Child Protective Services (CPS) in the United states involving seven.8 meg children. Nigh 2.4 million of these reports were investigated in detail and virtually 678,000 maltreated children were identified. Both sexes are affected equally overall, but boys are more oft physically driveling. The younger the kid is, the higher the rate of victimization.

About iii fifths of all reports to Child Protective Services were made by professionals who are mandated to written report maltreatment (eg, educators, police force enforcement personnel, social services personnel, legal professionals, day intendance providers, medical or mental health personnel, foster care providers).

Of substantiated cases in the U.s. in 2018, 60.8% involved just neglect (including medical neglect), 10.7% involved only physical abuse, and 7% involved just sexual corruption. Many children (xv.5%) were victims of multiple types of maltreatment.

Potential perpetrators are defined slightly differently in different states of the Usa, but in general, to be considered abuse, deportment must exist washed by a person responsible for the kid'due south welfare. Thus, parents and other relatives, people living in the child's dwelling who take occasional responsibleness, teachers, bus drivers, counselors, and so along may exist perpetrators. Unrelated people who commit violence against children who they have no connection to or responsibleness for (eg, as in school shootings) are guilty of assault, murder, and so forth simply are non committing child corruption.

• 1. The states Department of Health & Homo Services, Assistants for Children and Families, Assistants on Children, Youth and Families, Children's Agency: Child maltreatment 2018 (2020). Available at the Children's Agency web site.

Unlike forms of maltreatment often coexist, and overlap is considerable. The 4 main forms include

• Physical abuse

• Sexual corruption

• Emotional abuse

• Neglect

Intentionally feigning, falsifying, or exaggerating medical symptoms in a child that results in potentially harmful medical interventions is considered a form of corruption (abuse in a medical setting).

Physical abuse involves a caregiver inflicting physical harm or engaging in deportment that create a high chance of harm. Assault past someone who is not a caregiver or in a position of responsibility to the child (eg, a shooter in a schoolhouse mass shooting) is not specifically child abuse. Specific forms include shaking, dropping, striking, biting, and burning (eg, by scalding or touching with cigarettes). Corruption is the most common cause of serious head injury in infants. In toddlers, abdominal injury is besides common.

Infants and toddlers are the most vulnerable considering the developmental stages that they may get through (eg, colic, inconsistent sleep patterns, atmosphere tantrums, toilet training) may frustrate caregivers. This age group is besides at increased risk because they cannot report their abuse. The adventure declines in the early on school years.

Whatever activity with a child that is done for the sexual gratification of an adult or significantly older child constitutes sexual abuse (see Pedophilic Disorder Pedophilic Disorder Pedophilic disorder is characterized by recurrent, intense sexually arousing fantasies, urges, or behaviors involving prepubescent or immature adolescents (usually ≤ 13 years); it is diagnosed... read more ). Forms of sexual abuse include intercourse, which is oral, anal, or vaginal penetration; molestation, which is genital contact without intercourse; and forms that exercise not involve physical contact past the perpetrator, including exposure of the perpetrator'south genitals, showing sexually explicit material to a child, and forcing a kid to participate in a sex act with another child or to participate in the product of sexual fabric.

Sexual abuse does not include sexual play, in which children close in age view or touch each other's genital area without force or coercion. The guidelines that differentiate sexual abuse from play vary from state to state, but in general sexual contact between individuals with a > four year (chronologically, or in mental or physical development) historic period difference is considered to be inappropriate.

Emotional abuse is inflicting emotional harm through the use of words or deportment. Specific forms include berating a child by yelling or screaming, spurning past belittling the child's abilities and achievements, intimidating and terrorizing with threats, and exploiting or corrupting by encouraging deviant or criminal beliefs. Emotional corruption can besides occur when words or actions are omitted or withheld, in essence becoming emotional neglect (eg, ignoring or rejecting children or isolating them from interaction with other children or adults).

Fail is the failure to provide for or meet a child's basic physical, emotional, educational, and medical needs. Neglect differs from corruption in that it unremarkably occurs without intent to harm.

Different types of neglect can be divers as

• Concrete fail includes failure to provide adequate food, article of clothing, shelter, supervision, and protection from potential damage.

• Emotional fail is failure to provide affection or love or other kinds of emotional support.

• Educational fail is failure to enroll a child in school, ensure omnipresence at school, or provide domicile schooling.

• Medical neglect is failure to ensure that a child receives appropriate intendance or needed handling for injuries or physical or mental disorders.

Still, failure to provide preventive care (eg, vaccinations, routine dental examinations) is not normally considered neglect.

Severe corporal punishment (eg, whipping, burning, scalding) clearly constitutes physical abuse, merely for bottom degrees of physical and emotional chastisement, the boundary between socially accepted behavior and corruption varies among dissimilar cultures. Besides, certain cultural practices (eg, female genital mutilation Female Genital Mutilation Female genital mutilation is practiced routinely in parts of Africa (ordinarily northern or cardinal Africa), where it is deeply ingrained as part of some cultures. It is also washed in some parts... read more ) are and then extreme they constitute abuse in the US. However, sure folk remedies (eg, coining, cupping Cupping Cupping (a manipulative and body-based do) is used in traditional Chinese medicine. Cupping is believed to increase claret flow to the site of awarding, thereby improving healing in... read more , irritant poultices) oft create lesions (eg, bruises, petechiae, small-scale burns) that can blur the line between adequate cultural practices and abuse.

Generally, abuse can be attributed to a breakup of impulse control in the parent or caregiver. Several factors contribute.

Parental characteristics and personality features can play a function. The parent'south own babyhood may take lacked affection and warmth, may not have been conducive to the evolution of adequate self-esteem or emotional maturity, and, in many cases, also included other forms of maltreatment. Abusive parents may see their children equally a source of unlimited and unconditional amore and look to them for the support that they never received. As a event, they may have unrealistic expectations of what their children tin can supply for them, they are frustrated easily and have poor impulse control, and they may exist unable to give what they never experienced. Drug or booze use may provoke impulsive and uncontrolled behaviors toward their children. Parental mental disorders also increase the run a risk of maltreatment.

Irritable, demanding, or hyperactive children may provoke parents' tempers, as may developmentally or physically disabled children, who ofttimes are more dependent than a typically developing kid. Sometimes stiff emotional bonds do not develop betwixt parents and children. This lack of bonding occurs more commonly with premature or ill infants separated from parents early in infancy or with biologically unrelated children (eg, stepchildren), increasing the adventure of abuse.

Situational stress may precipitate abuse, peculiarly when emotional back up of relatives, friends, neighbors, or peers is unavailable.

Physical corruption, emotional abuse, and neglect are associated with poverty and lower socioeconomic status. However, all types of abuse, including sexual corruption, occur across the spectrum of socioeconomic groups. The gamble of sexual corruption is increased in children who have several caregivers or a caregiver who has several sexual activity partners.

Fail commonly results from a combination of factors such as poor parenting, poor stress-coping skills, unsupportive family systems, and stressful life circumstances. Neglect frequently occurs in impoverished families experiencing financial and environmental stresses, especially those in which parents also accept untreated mental disorders (typically depression, bipolar disorder, or schizophrenia), abuse drugs or alcohol, or have limited intellectual capacity. Children in unmarried-parent families may be at adventure of neglect due to a lower income and fewer available resource.

Symptoms and Signs of Child Maltreatment

Symptoms and signs depend on the nature and duration of the corruption or neglect.

Physical abuse

Peel lesions are common and may include

• Handprints or oval fingertip marks caused past slapping or grabbing and shaking

• Long, bandlike ecchymoses caused by chugalug whipping

• Narrow arcuate bruises caused by extension cord whipping

• Multiple small, round burns caused by cigarettes

• Symmetric scald burns of upper or lower extremities or buttocks caused past intentional immersion

• Seize with teeth marks

• Thickened skin or scarring at the corners of the oral cavity caused by being gagged

• Patchy baldness, with varying hair lengths, caused by pilus pulling

Fractures highly indicative of physical corruption include archetype metaphyseal lesions, rib fractures, and spinous processes fractures. Fractures most frequently associated with concrete abuse include skull fractures, long bone fractures, and rib fractures. In children < 1 yr old, about 75% of fractures are inflicted by others.

Confusion and localizing neurologic abnormalities tin can occur with cardinal nervous organization injuries. Lack of visible caput lesions does not exclude traumatic brain injury, particularly in infants subjected to tearing shaking. These infants may be comatose or stuporous from brain injury withal lack visible signs of injury (with the common exception of retinal hemorrhage) or they may present with nonspecific signs such every bit fussiness and airsickness. Traumatic injury to organs within the breast or abdominal/pelvic region may also occur without visible signs.

Sexual corruption

In most cases, children practice not spontaneously disembalm sexual abuse and rarely exhibit behavioral or physical signs of sexual corruption. If a disclosure is made, it is mostly delayed, sometimes days to years. In some cases, abrupt or extreme changes in behavior may occur. Aggressiveness or withdrawal may develop, as may phobias or sleep disturbances. Some sexually driveling children human action in ways that are sexually inappropriate for their historic period.

Physical signs of sexual abuse that involves penetration may include

• Difficulty in walking or sitting

• Bruises or tears around the genitals, anus, or oral cavity

• Vaginal discharge, haemorrhage, or pruritus

Other manifestations include a sexually transmitted infection, and pregnancy. Within a few days of the corruption, examination of the genitals, anus, and mouth will likely be normal, but the examiner may find healed lesions or subtle changes.

Emotional corruption

In early infancy, emotional abuse may blunt emotional expressiveness and decrease interest in the environment. Emotional abuse commonly results in failure to thrive and is frequently misdiagnosed equally intellectual disability or physical disease. Delayed evolution of social and linguistic communication skills frequently results from inadequate parental stimulation and interaction. Emotionally abused children may be insecure, anxious, distrustful, superficial in interpersonal relationships, passive, and overly concerned with pleasing adults. Children who are spurned may have very low self-esteem. Children who are terrorized or threatened may seem fearful and withdrawn. The emotional effect on children unremarkably becomes apparent at school historic period, when difficulties develop in forming relationships with teachers and peers. Often, emotional furnishings are appreciated only after the kid has been placed in another environment or after aberrant behaviors abate and are replaced past more acceptable behaviors. Children who are exploited may commit crimes or abuse alcohol and/or drugs.

Fail

• one. Pierce MC, Kaczor K, Aldridge S, et al: Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 125(ane):67–74, 2010. doi: 10.1542/peds.2008-3632

• High index of suspicion (eg, for history that does not match physical findings or for atypical injury patterns)

• Supportive, open-ended questioning

• Sometimes imaging and laboratory tests

• Reporting to authorities for farther investigation

Evaluation of injuries and nutritional deficiencies is discussed elsewhere in THE MANUAL. Recognizing maltreatment equally the cause can be difficult, and a high index of suspicion must be maintained. Because of social biases, corruption is considered less often in children living in a 2-parent household with an at to the lowest degree median-level income. Even so, child abuse can occur regardless of family unit composition or socioeconomic status.

Sometimes direct questions provide answers. Children who accept been maltreated may describe the events and the perpetrator, only some children, particularly those who take been sexually abused, may be sworn to secrecy, threatened, or so traumatized that they are reluctant to speak almost the abuse (and may even deny abuse when specifically questioned). A medical history including a history of the events should exist obtained from children and their caregivers in a relaxed environment. Open-ended questions (eg, "Can you lot tell me what happened?") are particularly important in these cases because aye-or-no questions (eg, "Did daddy do this?", "Did he touch you here?") can easily sculpt an untrue history in young children.

Examination includes ascertainment of interactions between the kid and the caregivers whenever possible. Documentation of the history and physical examination should be equally comprehensive and authentic as possible, including recording of exact quotes from the history and photographs of injuries.

Ofttimes it is unclear afterwards the initial evaluation whether abuse occurred. In such cases, the mandatory reporting requirement of suspected abuse allows appropriate authorities and social agencies to investigate; if their evaluation confirms abuse, advisable legal and social interventions tin be done.

Both history and physical examination provide clues suggestive of maltreatment.

Features suggestive of abuse in the history are

• Parental reluctance or inability to give the history of a significant injury

• History that is inconsistent with the injury (eg, bruises on the backs of the legs attributed to a forward autumn) or apparent stage of resolution (eg, old injuries described every bit recent)

• History that varies depending on the data source or over time

• History of injury that is incompatible with the child's stage of evolution (eg, injuries ascribed to rolling off a bed in an babe too young to curlicue over, or to a autumn down stairs in an infant besides young to crawl)

• Inappropriate response by the parents to the severity of the injury—either overly concerned or unconcerned

• Delay in seeking intendance for the injury

Major indicators of abuse on examination are

• Singular injuries

• Injuries incompatible with stated history

Childhood injuries resulting from falls are typically alone and occur on the forehead, chin, or mouth or extensor surfaces of the extremities, particularly elbows, knees, forearms, and shins. Bruises on the buttocks and the back of the legs are extremely rare from falls. Fractures, apart from clavicular fracture, tibial (toddler'due south) fractures, and distal radius (Colles) fracture, are less common in typical falls during play or down stairs. No fractures are pathognomonic of corruption, but archetype metaphyseal lesions, rib fractures (especially posterior and 1st rib), and depressed or multiple skull fractures (caused by allegedly minor trauma), scapular fractures, sternal fractures, and barbed processes fractures should raise concern for abuse.

Children < 36 months old (previous recommendation 24 months) with possible concrete abuse should undergo a skeletal survey for evidence of previous bony injuries (fractures in various stages of healing or subperiosteal elevations in long bones). Surveys are rarely washed on children > 3 years onetime. The standard survey includes images of the

• Appendicular skeleton: Humeri, forearms, hands, femurs, lower legs, and feet

• Axial skeleton: Thorax (including oblique views), pelvis, lumbosacral spine, cervical spine, and skull

(See as well updated guidelines for the medical assessment and care of children who may take been sexually abused.)

Sexually transmitted infections Overview of Sexually Transmitted Diseases Sexually transmitted diseases (STDs), too termed sexually transmitted infections (STIs), tin can be caused by a number of microorganisms that vary widely in size, life cycle, the diseases and symptoms... read more (2 Diagnosis references Kid maltreatment is behavior toward a child that is exterior the norms of conduct and entails substantial risk of causing physical or emotional harm. Four types of maltreatment are generally... read more than ) in a child < 12 years old should brand practitioners extremely suspicious well-nigh the possibility of sexual abuse. When a child has been sexually abused, behavioral changes (eg, irritability, fearfulness, insomnia) may be the only clues initially. If sexual abuse is suspected, the perioral and anal areas and the external genitals must be examined for bear witness of injury. If the suspected abuse is thought to take occurred recently (≤ 96 hours), forensic evidence should exist gathered using an appropriate kit and handled according to required legal standards (see Testing and prove collection Testing and evidence collection Although legal and medical definitions vary, rape is typically divers as oral, anal, or vaginal penetration that involves threats or force confronting a person who is unwilling (ie, nonconsenting)... read more ). An examination involving utilize of a magnifying calorie-free source with a camera, such every bit with a specially equipped colposcope, may exist helpful to the examiner as well as for documentation for legal purposes.

Evaluation focuses on general appearance and beliefs to determine whether the child is declining to develop normally. Teachers and social workers are often the outset to recognize neglect. The physician may notice a pattern of missed appointments and vaccinations that are non up-to-date. Medical neglect of life-threatening, chronic diseases, such as asthma or diabetes, can pb to a subsequent increase in office or emergency department visits and poor adherence with recommended treatment regimens.

• i. Maguire SA, Watts PO, Shaw AD, et al: Retinal haemorrhages and related findings in calumniating and non-abusive head trauma: A systematic review. Centre (Lond) 27(1):28–36, 2013. doi: 10.1038/eye.2012.213

• Treatment of injuries

• Reporting to the appropriate agency

• Creation of a safety plan

• Family counseling and support

• Sometimes removal from the abode

Handling first addresses urgent medical needs (including possible sexually transmitted infections) and the child's immediate safety. Referral to a pediatrician specializing in child corruption should be considered. In both abuse and neglect situations, families should exist approached in a helping rather than a punitive manner.

Physicians and other professionals in contact with children (eg, nurses, teachers, day care workers, police) are mandated reporters who are required by constabulary in all states to report incidents of suspected abuse or neglect (see Mandatory Reporters of Kid Corruption and Neglect). Every country has its own laws. Members of the general public are encouraged, but not mandated, to report suspected corruption. Whatever person who makes a report of abuse based on reasonable cause and in good faith is allowed from criminal and civil liability. A mandated reporter who fails to make a study tin can be subject to criminal and civil penalties. The reports are made to Kid Protective Services or some other advisable child protection agency. In most situations, information technology is appropriate for professionals to tell caregivers that a written report is existence made pursuant to the constabulary and that they volition be contacted, interviewed, and likely visited at their home. In some cases, the professional may make up one's mind that informing the parent or caregiver before police or other agency assist is bachelor creates greater gamble of injury to the child and/or themselves. Under those circumstances, the professional may cull to filibuster informing the parent or caregiver.

Representatives of child protective agencies and social workers conduct an evaluation of the events and the child'south circumstances and can aid the physician determine likelihood of subsequent harm and thus place the best firsthand disposition for the child. Options include

• Protective hospitalization

• Placement with relatives or in temporary housing (sometimes a whole family is moved out of an abusive partner'south home)

• Temporary foster intendance

• Going home with prompt social service and medical follow-up

The physician plays an of import role in working with customs agencies to advocate for the best and safest disposition for the child. Healthcare professionals in the Us are often asked to write an impact statement, which is a letter typically addressed to a Child Protective Services worker (who can so bring information technology to the attention of the judicial system), about a child who is suspected to exist the victim of maltreatment. The letter should comprise a clear explanation of the history and concrete examination findings (in layman's terms) and an opinion as to the likelihood that the kid was maltreated.

A source of primary medical intendance is fundamental. However, the families of abused and neglected children oft relocate, making continuity of care difficult. Cleaved appointments are common; outreach and home visits past social workers and/or public health nurses may be helpful. A local child advocacy center can help community agencies, health care practitioners, and the legal system work together as a multidisciplinary squad in a more than coordinated, kid-friendly, and constructive mode.

A shut review of the family setting, prior contacts with various community service agencies, and the caregivers' needs is essential. A social worker can comport such reviews and help with interviews and family counseling. Social workers likewise provide tangible assistance to the caregivers by helping them obtain public assistance, child care, and respite services (which can decrease stress for caregivers). They can also help to coordinate mental health services for caregivers. Periodic or ongoing social work contact usually is needed.

Parent-aide programs, which employ trained nonprofessionals to support abusive and negligent parents and provide an example of appropriate parenting, are available in some communities. Other parent support groups also take been successful.

Sexual abuse may have lasting furnishings on the child's development and sexual adaptation, specially among older children and adolescents. Counseling or psychotherapy for the child and the adults concerned may lessen these effects. Physical corruption, specially significant head trauma, also can have long-lasting effects on development. If physicians or caregivers are concerned that young children have a disability or delayed development, they may request an evaluation from their state'due south Early on Intervention organisation (see Early Intervention Services), which is a program to evaluate and treat children with suspected disabilities or developmental delays.

Although emergency temporary removal from the home until evaluation is complete and safety is ensured is sometimes done, the ultimate goal of Child Protective Services is to go on children with their family unit in a condom, good for you environment. Often, families are offered services to rehabilitate the caregivers and then that children who have been removed may be reunited with their family. If the previously described interventions do not ensure safety, consideration must exist fabricated for long-term removal and perhaps termination of parental rights. This significant pace requires a court petition, presented past the legal counsel of the advisable welfare section. The specific process varies from state to country only usually entails family courtroom testimony past a physician. When the court decides in favor of removing the child from the home, a disposition is arranged, typically to a temporary placement, such as foster intendance. While the kid is in temporary placement, the kid'southward own physician or a medical team that specializes in children in foster care should, if possible, maintain contact with the parents and ensure that acceptable efforts are beingness fabricated to help them. Occasionally, children are re-abused while in foster care. The physician should exist alarm to this possibility. Every bit the dynamics of the family setting improve, the child may be able to render to the original caregivers. However, recurrences of maltreatment are mutual.

Prevention of maltreatment should exist a role of every well-child office visit through pedagogy of parents, caregivers, and children and identification of risk factors. At-adventure families should be referred to advisable customs services.

Parents who were victims of maltreatment are at increased chance of abusing their own children. These parents sometimes verbalize anxiety near their abusive background and are acquiescent to assistance. Kickoff-time parents and teenage parents as well as parents with several children < 5 years of age are likewise at increased run a risk of abusing their children. Often, maternal risk factors for corruption are identified prenatally (eg, a mother who smokes, abuses drugs, or has a history of domestic violence). Medical problems during pregnancy, delivery, or early infancy that may impact the health of the mother and/or the baby can weaken parent-infant bonding (come across also Caring for Ill Neonates Caring for Sick Neonates Difficulties arise when a sick or premature infant must be taken away from the family unit subsequently birth because of affliction. The parents may not be able to see a critically sick infant during stabilization... read more than ). During such times it is important to elicit the parents' feelings about themselves and the infant'due south well-being. How well can they tolerate an babe with many needs or wellness demands? Do the parents give moral and concrete back up to each other? Are in that location relatives or friends to aid in times of demand? The health care practitioner who is alert to clues and able to provide support tin can brand a major touch on on the family and possibly foreclose child maltreatment.

The following are some English language-linguistic communication resource that may be useful. Please notation that THE Transmission is not responsible for the content of these resources.

• Child Welfare Information Gateway: Child welfare information gateway from the Us government containing guidance on many aspects of kid abuse also equally listings of land and federal resources

• Preclude Child Abuse America: Children's charity focusing on child corruption with much useful information for parents and health care practitioners and information about public policy

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Source: https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment