Child maltreatment

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, 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.

• 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 children/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)
    • Low education
    • Unemployment, financial hardship
    • Personal history of abuse during childhood
    • Domestic violence
  • 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.
  • Interview child and parent/caregiver separately if possible.
  • Keep verbatim record.
  • Admit to hospital for medical stabilization if required.
  • Document in detail the characteristics (location, size, shape, color, nature) of the lesion(s).
  • Perform an ophthalmologic exam and skeletal survey if appropriate.

Suspect child maltreatment if one or several of the following apply: the presence of risk factors, history does not fit clinical findings or pattern of behavior for child age, the 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]}

• 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
  • Avoiding medical treatment when required (e.g., physical injuries)
  • Failure to enroll a child in school or homeschooling
  • Absent preventative care measures (e.g., necessary vaccinations)
• Clinical features
  • Neonates
    • Apnea
    • Irritability
    • Feeding intolerance
    • Failure to thrive
    • Seizures
  • Older children
    • Abnormal language, social, and/or emotional development
    • Absence of fundamental trust towards others
    • Reactive attachment disorder
    • Disinhibited social engagement disorder (social attachment to strangers without inhibition) due to emotional neglect during infancy
    • Poor overall appearance and clothing
• Prognosis: Long-term (> 6 months) and/or severe neglect during infancy may result in irreversible personality changes and even death.

Child neglect is the most common form of child maltreatment.

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

• Definition: non-accidental injury caused to a child
• Epidemiology
  • ∼ 40% of deaths occur in children < 1 year of age.
  • The perpetrator is usually the primary caregiver (e.g., mother).
• Etiology
  • Burns (e.g., scalds): sharply delineated patterns , multiple burns of different ages and localizations
  • Inflicted head trauma, e.g., shaken baby syndrome (see below)
  • Battered child syndrome
    • Injuries showing different states of healing in a child, resulting from long-term physical violence
    • X-rays may show different stages of bone healing.
    • Ligature marks

Suspicious bruises (TEN4): Torso, Ear, Neck, any bruise in these locations in children ≤ 4 years of age and any bruise (regardless of location) in infants < 4 months of age

References:^{[7][9][10][11][12]}

• 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 ; ^[13]
  • Rotational and shearing forces → shearing off of bridging veins → subdural hematoma
  • Shaking of the child with a weak neck support → respiratory problems and apnea → hypoxia → brain edema and ischemia → diffuse axonal damage
• Clinical findings
  • Inconsistent or implausible history from caretakers
  • Injuries are hardly evident or entirely absent on physical exam.
  • Retinal hemorrhages
  • Irritability or lethargy
  • Seizures
  • Vomiting
  • Tense fontanelle
  • Long-term: sight, hearing, and speech impairment; massive neurological deficits
  • Associated injuries
    • Rib fractures
    • Visceral injuries (e.g., liver laceration, visceral hematoma)
    • See also “Battered child syndrome”.
• Diagnostics
  • Non-contrast CT
    • Subdural hematomas and/or subarachnoid hemorrhage of varying ages
    • Reversal sign: diffuse blurring of the grey-white matter interface
    • Diffuse punctate hemorrhages: variable localization, but most often interhemispheric
  • Skeletal survey
  • MRI: if CT findings are abnormal, or in asymptomatic children with noncranial injuries

Approx. 25% of children who suffer abusive head trauma die.

References:^{[14][15][16][17]}

Scalding does not characteristically affect the hair and eyelashes. Singed hair and eyelashes imply direct exposure to flames.

References:^[7][9]

• Definition: involvement of a child in sexual activity with an adult or an older child
• Epidemiology
  • Peak incidence: 9–12 years of age
  • The perpetrator is usually male and known to the child.
  • ∼ 8.5% of all victimized children
• Etiology
  • Sexual intercourse (oral, anal, or vaginal penetration)
  • Molestation (genital contact without penetration)
  • Exposure to a perpetrator's genitalia
  • Forced sexual interaction with another child or object
  • Exposure to explicit material
• Clinical features
  • Often no visible signs on physical examination
  • Behavior or sexual insights which are inconsistent with age
  • Injuries in the genital, anal, and oral areas
  • Recurrent urinary tract infections
  • Signs and symptoms of sexually transmitted diseases
  • Pregnancies
• Differential diagnosis: foreign objects in girls
• Diagnostics
  • Suspicious STDs beyond the neonatal period
    • Gonorrhea
    • Chlamydia trachomatis infection
    • Herpes infection
    • Syphilis
    • Nontransfusion, perinatally acquired HIV
  • Test for STDs ideally within 72 hours of the assault.

Even in the absence of physical signs, sexual abuse should always be considered in young children presenting with behavioral changes or signs of sexually transmitted diseases.

References:^{[3][4][18][19][20]}

• Definition: actions and behaviors from parents or caregivers that have a negative mental impact on the child
• Epidemiology: Approx. 80% of survivors fit the criteria for at least 1 psychiatric condition by the age of 21.
• 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)
• Clinical features
  • Detachment from a caregiver or from other children (reactive attachment disorder)
  • Children or babies seem to attach more to random adults rather than to their primary caregiver
  • Aggression towards other children or animals
  • Overly distressed
  • Frequent tantrums (in older children)
  • Complaining about somatic symptoms with no identifiable medical cause

References:^[3]

• 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 (See “Munchausen syndrome by proxy”)
• Etiology
  • Administering inappropriate drug therapy or other agents to induce symptoms
  • Simulating disease (e.g., contaminating body urine specimens)

References:^[21]