• Clinical science

Child maltreatment (Child abuse and neglect)

Abstract

Child maltreatment consists of any act or failure to act by a parent or caretaker resulting in any potential or overt physical or psychological harm, sexual abuse or exploitation, or death of a child. Up to 25% of American children experience some form of child maltreatment. Major risk factors include the following: less than four years of age, caregiver(s) with substance use disorders, and intimate partner violence in the household. The most common form of child maltreatment is neglect, followed by physical abuse, sexual abuse, psychological maltreatment, and medical neglect. Common clinical presentations of child maltreatment include growth retardation and developmental delays secondary to neglect, trauma inconsistent with history or developmental stage secondary to physical abuse, and STDs, pregnancy, and genitourinary complaints secondary to sexual abuse. When the differential diagnosis includes child maltreatment, the first diagnostic step is a thorough history and physical exam. Ophthalmologic exam and a skeletal survey should also be performed if appropriate. Management includes medical stabilization if necessary and immediately reporting any suspected child maltreatment to Child Protective Services (CPS). Laws vary by state but typically designate physicians as mandatory reporters. Because more than 1,600 children die each year from child maltreatment, it is essential to have a high index of suspicion and a low threshold for reporting.

Overview

  • Definition: any act or failure to act by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child
  • Epidemiology
    • Incidence: 683,000 victims/year (2015)
    • Up to 25% of American children experience some form of child maltreatment.
  • Risk factors
    • Perpetrator factors
      • Alcoholism, drug abuse, and/or mental health issues (e.g., depression)
      • Personal history of abuse during childhood
      • Domestic violence
      • Low education
      • Unemployment, financial hardship
    • Child factors
      • Age < 4 years
      • Physical or mental disablement
  • Classification
    • Child neglect
    • Physical abuse
    • Sexual abuse
    • Psychological maltreatment
    • Medical neglect
  • Management
    • Always notify Child Protective Services
    • Medical stabilization and hospital admission (if required)
    • Document in detail the characteristics (location, size, shape, color, nature) of the lesion(s)
    • Ophthalmologic exam and skeletal survey if appropriate

Suspect child maltreatment if one or several of the following apply: presence of risk factors, history does not fit clinical findings or pattern of behavior for child age, story continually changes, delay in seeking medical treatment, highly suspicious injuries. It is essential to have a high index of suspicion and a low threshold for reporting!
References:[1][2][3][4][5][6]

Child neglect

  • Definition: failure to meet a child's basic physical, emotional, medical, or educational needs
  • Etiology
    • Failure to provide appropriate food, clothing, or shelter
    • Poor supervision and protection from potential harm
    • Denying emotional support and social interaction
    • Failure to enroll a child in school or homeschooling
    • Absent preventative care measures (e.g., necessary vaccinations)
    • Avoiding medical treatment when required (e.g., physical injuries)
  • Clinical features

Child neglect is the most common form of child maltreatment!

References:[3][4][7][8]

Physical abuse

  • Definition: non-accidental injury caused to a child
  • Epidemiology
    • 40% of fatal victims are < 1 year of age
    • The perpetrator is usually the primary caregiver or mother.
  • Etiology
    • Burns
      • Scald burns
      • Sharply delineated patterns , multiple burns of different ages and localizations
    • Shaken Baby Syndrome (see below)
    • Battered child syndrome
      • Injuries showing different states of healing in a child, resulting from long-term physical violence
      • Ligature marks
      • X-rays may show different stages of bone healing.
Injuries Suspicious Unsuspicious
Localization
Pattern
  • Evenly distributed
  • Multiple injuries of different ages and localizations
  • Unevenly distributed

Suspicious bruises (TEN4): T – Torso, E – Ear, N – Neck, 4 – (any bruise in these locations) in children ≤ 4 years of age and ANY bruise in infants < 4 months of age

References:[9][7][10][11][12]

Shaken baby syndrome (abusive head trauma)

  • Definition: head trauma through strong rotational and shearing force
  • Epidemiology: : high mortality and a significant cause of death
  • Etiology: violent shaking of a child
  • Pathophysiology: : rotational and shearing forces → shearing off of bridging veinsdiffuse axonal damage
  • Clinical findings
    • Inconsistent or implausible history from care takers
    • From the outside, injuries are hardly evident or entirely absent
    • Retinal hemorrhages
    • Irritability or lethargy
    • Seizures
    • Vomiting
    • Tense fontanelle
    • Long-term: sight, hearing, and speech impairment; massive neurological deficits
    • Associated injuries :
  • Diagnostics
    • Non-contrast CT
      • Subdural and/or subarachnoid hemorrhage
      • Reversal sign: diffuse blurring of the grey-white matter interface
      • Diffuse punctate hemorrhages: variable localization, but most often interhemispheric
      • Multiple subdural hematomas of varying ages may be seen
    • Skeletal survey
    • MRI: if CT findings are abnormal, or in asymptomatic children with noncranial injuries

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25% of children who suffer abusive head trauma die!
References:[13][14][15][16]

Scald Burns

Abuse (immersion of the child) Accidental
Delineation
  • Clearly delineated from healthy skin
  • Symmetrical
  • No clear delineation
  • Asymmetrical

Injury depth

  • Similar injury depth in all areas
  • Differing injury depth
Scald marks
  • No marks from spills of water when immersing solitary body parts
  • Third-degree burns on the back, buttocks, and thighs
  • Sparing of flexor surfaces
  • Suggestive patterns:
    • Doughnut pattern
    • Zebra pattern .
    • Stocking or glove pattern
  • Typical marks left by spills of water in recesses, e.g., arrow-like marks in the chest area
  • Splash marks

Extremities

  • Scalding by immersion: scalding (sock-like) of the entire foot/of the entire hand
  • Uneven scalding
  • Mottled scalding

Scalding does not characteristically affect the hair and eyelashes! Singed hair and eyelashes imply direct exposure to flames!
References:[9][7]

Sexual abuse

  • Definition: involvement of a child in sexual activity with an adult or an older child
  • Epidemiology
    • Peak incidence: 9–12 years of age
    • 8.4% of victimized children
    • The perpetrator is usually male and known to the child.
  • Etiology
    • Sexual intercourse (oral, anal, or vaginal penetration)
    • Molestation (genital contact without penetration)
    • Exposure to perpetrators genitalia
    • Exposure to explicit material
    • Forced sexual interaction with another child or object
  • Clinical features
  • Differential diagnosis: foreign bodies in girls
  • Diagnostics

References:[3][4][17][18][19]

Psychological maltreatment

  • Definition: actions and behaviors from parents or caregivers that have a negative mental impact on the child
  • Etiology
    • Name calling, insulting, intimidation, or threats of violence
    • Allowing the child to see abuse being inflicted on another (e.g., partner abusing the mother)

References:[3]

Medical abuse

  • Definition: : consists of providing nonrequired and potentially harmful medical care to a child, as a result of fabrication or exaggeration of symptoms by parents or caregivers
  • Etiology
    • Administering inappropriate drug therapy or other agents to induce symptoms
    • Simulating disease (e.g., contaminating body urine specimens)

References:[20]