Child Abuse

Child abuse is defined as any abuse or neglect of a child under 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, coach, or teacher) that results in harm, potential for harm, or threat of harm.  It includes:

  • Physical Abuse
  • Sexual Abuse
  • Emotional Abuse
  • Neglect

Child abuse is common, affecting an estimated 700,000 to 1.25 million US children annually. It is the 3rd leading cause of death in children between one and four years of age, and almost 20% of child homicide victims have contact with a healthcare professional within a month of their death.  Pediatricians and family physicians are positioned to detect possible child maltreatment, but clinicians may miss physical or psychological abuse injuries at first presentation. It is important to be vigilant for potential abuse while recognizing the potential for bias and errors.

Determining whether a child is being abused is complicated and requires a thoughtful and often multi-disciplinary approach to evaluation. If abuse is suspected, further history about possible abuse should be obtained by a provider with expertise.

Physical findings that suggest possible abuse

Bruising is the most common and most visible sign of physical abuse. It may be the only sign of injury or signal of internal injury. Unfortunately, bruising is missed in up to 44% of fatal or near fatal cases.  Children that are not yet mobile should not have falls or other injuries that cause bruising – remember that “those that don’t cruise, rarely bruise.”  A bruise in any child under 4 months of age is concerning.

The TEN-4-FACES Bruising Clinical Decision Rule was developed and validated at the University of Chicago. It is intended to be used as a screening tool to improve the recognition of potentially abused children who require further evaluation.

 

Ten-4-FACES Bruising Clinical Decision Rule for screening to improve the recognition of child abuse. It was developed and validated at the University of Chicago. Unexplained bruising of the torso, ears, neck, and specific points on the face in children over 4 months most often result from physical assault. Any bruise, anywhere suggests abuse in an infant 4 months or younger.

Mandated reporting of suspected abuse

Health care workers, teachers, social workers, counselors, child care providers and law enforcement officers are designated as mandatory reporters, meaning that they are legally required to report suspected abuse to the appropriate state protective services agency. The law and process varies somewhat state-to-state. For more information on laws in your state as well as an overview of how the child welfare system works, visit the Child Welfare Information Gateway

If you are concerned about the possibility of abuse or neglect of a child, please reach out to your preceptors, your attending physicians in clinical years, or your mentors to discuss and to help you navigate the next steps.  You’ll learn more about detecting and responding to child maltreatment and abuse in your Pediatric Clerkships.

Resources and references

University of Chicago Stanley Mann Children’s Research Institute. TEN-4-Faces-P. Online. 

StatPearls. Child Abuse and Neglect. Online. 

CDC Child Abuse and Neglect Prevention: https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html

Child Care Health and Safety Violations: State and Territory Reporting Information:  https://childcare.gov/Health-and-Safety-Reporting

Mandatory Reporters of Child Abuse and Neglect: https://www.childwelfare.gov/pubPDFs/manda.pdf

Cribsiders Podcast “Non Accidental Trauma”

License

The Foundations of Clinical Medicine Copyright © by Karen McDonough. All Rights Reserved.