Aspects of Abuse: Recognizing and Responding to Child Maltreatment
Introduction
Child maltreatment is a public health problem that encompasses both the abuse and neglect of children by a parent or caregiver, which respectively include acts of commission and omission. Although the pediatric population includes young adults in their late teens and early 20s, child abuse and neglect refers to children and youth below the age of 18 years in keeping with the legal definition of a child. Maltreatment, however, can and does occur across the lifespan. According to federal definition as delineated in the Child Abuse Prevention and Treatment Act (CAPTA) as Amended by P.L. 111-320, the CAPTA Reauthorization Act of 20101
the term “child abuse and neglect” means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm;
Child abuse includes physical, sexual, and emotional acts toward children and youth, while child neglect includes physical, emotional, medical, educational, and supervisional acts of omission. More specifically, neglect occurs when the basic needs of a child are not being met. These needs include the emotional, educational, nutritional, physical, supervisional, and medical needs for children and youth. Neglect can result from the willful omission or disregard for the child or from a lack of ability or resources. In either case, the impact of the neglect on child well-being can be the same. Child physical abuse includes physical acts that harm or have the potential to harm or injure children. Such acts can include hitting, kicking, punching, beating, stabbing, biting, pushing, shoving, throwing, pulling, dragging, dropping, shaking, strangling/choking, smothering, burning, scalding, and poisoning. According to CAPTA,1 sexual abuse is defined as
the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.
Sexual assault is different in that the perpetrator can be an acquaintance, stranger, or other individual who is not in a caregiving role. Medical Child Abuse is more complex form of maltreatment in which a caregiver fabricates, exaggerates, and/or induces signs and symptoms of illness resulting in excessive utilization of medical care and interventions.2, 3, 4 It is not only physically abusive but also has elements of emotional maltreatment and neglect. Emotional maltreatment can entail both acts of commission and acts of omission that negatively impact the well-being of a child. It is defined best in the American Academy of Pediatrics׳ 2012 Clinical Report, which states
Caregiver behaviors include acts of omission (ignoring need for social interactions) or commission (spurning, terrorizing); may be verbal or nonverbal, active or passive, and with or without intent to harm; and negatively affect the child׳s cognitive, social, emotional, and/or physical development.5
In addition to the uniquely complex forms of maltreatment such as child torture and Medical Child Abuse, which incorporate physical abuse, emotional abuse, and neglect, many children experience more than one form of maltreatment.6 The impact of child maltreatment on child well-being is great. Consequently, recognizing signs and symptoms of abuse and neglect, and making appropriate referrals for assessment and treatment are critical skills for health care providers.7 By recognizing and appropriately responding to child maltreatment, ongoing and potentially escalating abuse can be interrupted and interventions can be implemented to improve outcomes for children and families.
Section snippets
Epidemiology
Child abuse is not rare, it is however, not always recognized, reported, or disclosed. The cumulative prevalence of substantiated cases of maltreatment based on the 2011 national rate of child maltreatment is 1 in 8 children by the age of 18 years.8 This rate is based on the number of substantiated cases of child maltreatment reported annually to child welfare agencies in the US. All reported abuse and neglect may not be substantiated in the child welfare system. Therefore, these rates provide
Recognition and Evaluation of Neglect
Child neglect is the most prevalent form of child maltreatment substantiated in the US child welfare system. Of the 678,810 victims of child abuse and neglect in FFY 2012, 78.3% were neglected (Fig 1); moreover, of the 1640 estimated fatalities from child abuse and neglect, 69.9% suffered neglect and 8.9% suffered medical neglect.13 The subtypes of neglect include educational neglect, emotional neglect, nutritional neglect, physical neglect, supervisional neglect, and medical neglect. Neglect
Recognition and Evaluation of Physical Abuse
Physical abuse can result in a variety of injuries of varying degrees of severity. The AAP committee on Child Abuse and Neglect has posited that “minor forms of abuse may lead to severe abuse unless abusive skin injuries are identified and labeled as such and interventions are made.”27 This statement highlights the fact that skin injuries are the most common presentation of physical abuse and that early identification is the best way to prevent future harm. Researchers have found that just over
Recognition and Evaluation of Sexual Abuse
The AAP recommends that pediatricians provide longitudinal sexual education to parents, children, and/or adolescents, counseling parents on what is normal sexuality and how to discuss sexuality with their children.36 Thus, screening for sexual abuse should occur at all well visits and if the child presents with genitourinary complaints or concerning behavioral/emotional problems that raise concern for sexual abuse.37 This includes age-appropriate discussions with children about privacy and
Recognition and Evaluation of Medical Child Abuse
In 1785, Raspe46 wrote about the Adventures of Baron Munchausen, a fabulist. As a tongue-in-cheek tribute to the Baron, Asher47 in 1951 wrote about adults who told “a matrix of fantasy and falsehood” to doctors and over-utilized medical care, coining the term “Munchausen׳s syndrome,” intrinsically linking adult actions to motive, noting a “psychological kink.”47 Meadow׳s481977 article on Munchausen syndrome by proxy discussed 2 cases in which a caregiver non-accidentally injured their child.
Recognition and Evaluation of Psychological Maltreatment
Pediatric providers are in a unique position to observe healthy and dysfunctional parent–child interactions and to intervene when those interactions are or can be harmful to the child. It is important to note that all poor parenting is not emotionally abusive or neglectful. There is a continuum of parenting that ranges from positive and healthy to psychological maltreatment.53 The risk of harm to the child is primarily what distinguishes dysfunctional parenting from psychological maltreatment.
Responding to Suspected Maltreatment
The response to suspected child maltreatment should always include reporting a reasonable suspicion to the appropriate child welfare agency. This should be done simultaneously with the initiation of additional studies for evaluation. Delaying a report until abuse can be medically proven is fraught with risk. Typically, mandated reporters are professionals who have frequent contact with children; therefore, all health care professionals are mandated reporters for child abuse and neglect.56
Medical and Mental Health Treatment
The child welfare system does not bear the sole responsibility of intervening on behalf of maltreated children. Child maltreatment is a toxic stress that can result in death as well as physical, developmental, and psychological impairment in those who survive. Therefore, pediatric providers are not only obligated to report suspicions, but they are also critical to the recovery and restoration of child victims. Early recognition of child maltreatment, assessing the extent and degree of injury,
Prevention and Anticipatory Guidance
Providers of pediatric health care have a unique opportunity to partner with parents to promote the health and well-being of children. While providers must be able to recognize and appropriately report suspicions for abuse and neglect, both the American Academy of Pediatrics and the Centers for Disease Control recognize the importance of promoting safe, stable, and nurturing relationships in order to prevent maltreatment.11 This partnership allows for providers to not only encourage healthy
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Cited by (32)
Defining suspected child maltreatment using International Classification of Diseases codes: A scoping literature review
2023, Children and Youth Services ReviewChild Maltreatment Prevention: Essentials for the Pediatric Nurse Practitioner
2022, Journal of Pediatric Health CareCitation Excerpt :Henry and Wood (2021); Hornor (2013); Sheets et al. (2013). Sexual abuse is typically revealed by child disclosure to a nonhealthcare professional (Jackson, Kissoon, & Greene, 2015). However, on rare occasions, children may present with sexual abuse concerns that are revealed during the health care visit: pregnancy, sexually transmitted infection, anogenital examination findings, or child disclosure of sexual abuse (Jenny, Crawford-Jakubiak, Committee on Child Abuse and Neglect, & American Academy of Pediatrics, 2013).
Using deep learning and natural language processing models to detect child physical abuse
2021, Journal of Pediatric SurgeryCitation Excerpt :When abuse is missed, children are more likely to return to abusive environments, where they face an increased risk of escalating abuse and death [1,3]. The ultimate determination of whether a child was abused or not can be challenging, because perpetrators infrequently admit to their actions, and many victims are preverbal, or may be too severely injured or too frightened to disclose the cause of their injuries [4,5]. In addition, the presentation of abuse can be subtle, and many abuse-related injuries are non-specific.
Child maltreatment is mediating long-term consequences of household dysfunction in a population representative sample
2019, European PsychiatryCitation Excerpt :These results underline the pivotal role of child maltreatment on various outcomes later in life and implies that effective interventions for families with household dysfunction need to ensure child protection as a priority. As age under 4 years is not only a known risk factor for maltreatment [56] - but also an age period that is particularly vulnerable [57,58] - interventions should start as soon as possible, e.g. during pregnancies. However, only the long-term consequences to mental and general health of IPV and incarceration of a household member were mediated completely by maltreatment.
Child abuse: Types and emergent issues
2019, Child Abuse and Neglect: Forensic Issues in Evidence, Impact and ManagementEvaluation of forensic medical history taking from the child in cases of child physical and sexual abuse and neglect
2017, Journal of Forensic and Legal MedicineCitation Excerpt :Physical abuse, sexual abuse and neglect are not uncommon and affect the lives of many children around the world.1