Whether a nurse in the emergency department or a school psychologist, healthcare professionals are often uniquely placed to spot the subtle signs of abuse in children, and use this information to help in preventing child abuse.
In recognition of National Child Abuse Prevention Month, we’re shining a light on the most common types of child abuse in the U.S., as well as reviewing the signs, risk factors, and mandated reporting policies that impact healthcare professionals.
Understanding and preventing child abuse
Tragically, child abuse comes in many forms. The most prevalent include neglect, physical, sexual, or emotional abuse, and FDIA, or Factitious Disorder Imposed on Another, also called Munchausen syndrome by proxy (MSbP).
While not always mutually exclusive, the U.S. Department of of Health and Human Services (HHS) defines each type of maltreatment by the following criteria:
- Neglect. The failure of a parent, guardian, or other caregiver to provide for the basic needs of the child, whether physical, emotional, educational, or medical. Many states consider the following to be forms of neglect:
- Abandonment. A child has been left alone in circumstances where they suffer serious harm, when the parent’s identity or whereabouts is unknown, or the parent has failed to maintain contact with the child or provide reasonable support for a specified period.
- Parental substance abuse. The child is exposed to the mother’s drug use in utero, or the child is present during the manufacture of methamphetamine. The child’s caretaker may use a controlled substance in such a way as it impairs their ability to care for the child.
- Human trafficking. The child is trafficked for sex and/or labor, which may include drug dealing, begging, or working for little pay.
- Physical abuse. The child receives an intentional physical injury (via biting, shaking, throwing, stabbing, punching, beating, kicking, choking, hitting, burning, or other means). To note, HHS does not consider physical discipline (spanking or paddling) abuse as long as it does not cause bodily injury and is reasonable.
- Sexual abuse. Includes fondling a child’s genitals, sodomy, indecent exposure, penetration, incest, rape, and exploitation through prostitution or the production of pornographic materials.
- Emotional or psychological abuse. The child is the subject of a pattern of behaviors that impair their sense of self-worth or emotional development. This may include threats, constant criticism, rejection, and/or withholding support, love, or guidance.
- Factitious Disorder Imposed on Another (FDIA), or Munchausen Syndrome by Proxy. The child’s caregiver either harms the child or fabricates symptoms of an illness in order to receive medical attention.
According to the Centers for Disease Control and Prevention (CDC), child abuse is the fourth leading cause of death in children between one and four years of age.
In 2017, 50 states reported a combined total of 1,688 fatalities from abuse and neglect. This represented a national rate of 2.32 deaths per 100,000 children. Of the children who died, 75.4% suffered from neglect and 41.6% suffered from physical abuse.
Perpetrators were most likely the parents of the children. Only 4.7% of perpetrators were a relative other than a parent.
Signs and symptoms of child abuse
Identifying symptoms of child abuse can prove difficult for healthcare professionals. There are often few witnesses to the abusive behavior besides the child and the perpetrator. The child may be preverbal, too injured, or too frightened to disclose the abuse to a stranger.
Psychosocial cues of abuse from the child may include sudden changes in behavior or school performance, extreme vigilance, reluctance to be around the perpetrator, or vague/contradictory explanations for major injuries.
Significant delays in seeking medical attention may also indicate abuse. An abuser may not bring the child to a doctor unless they perceive the injury to be life-threatening.
A neglected child may exhibit unaddressed medical or dental needs. They may steal food or money, have frequent absences at school, or lack weather-appropriate clothing. They may also abuse alcohol or drugs or demonstrate persistent poor hygiene.
Abuse can take place in any household. There are several factors that contribute to the likelihood of an abusive environment, including:
- A high density of alcohol outlets in the vicinity
- Non-biologically related male living in the home
- A stressful environment
- A history of violence
- Social isolation
Risk factors for victims may involve emotional or behavioral difficulties, physical or developmental disabilities, unplanned pregnancies or a preterm birth, or chronic illness.
Perpetrators may exhibit patterns of low self-esteem, substance and alcohol abuse. They may also exhibit antisocial personality disorder, depression, and mental illness. Additionally, they may have experienced domestic or intimate partner violence or have a history of abuse in their own childhoods.
For social workers: Intimate Partner Violence: Recognition and Intervention, 2nd Edition
Reporting suspected abuse
The legal definitions and reporting requirements for child abuse and neglect vary from state to state. However, all 50 states require mandated reporting of suspected abuse or neglect by healthcare professionals to a CPS agency.
For those who may suspect child abuse or neglect, it’s critical to ensure the child’s immediate safety, including medical treatment. That may involve the police, relatives, or foster care, as well as CPS.
For more information on state-specific statutes and policies regarding child welfare, visit the U.S. Department of Health and Human Services’ resource portal.
This article is based on the 6-hour Child Abuse: Identification, Management, and Reporting course written by Margaret Nihoul, MSN, RN, CPRNP-PC.