Aspects of Abuse: Recognizing and Responding to Child Maltreatment

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Child maltreatment is a public health problem and toxic stress impacting at least 1 in 8 children by the age of 18 years. Maltreatment can take the form of physical and sexual abuse, neglect, and emotional maltreatment. While some children may experience only one form of maltreatment, others may survive multiple forms, and in some cases particularly complex forms of maltreatment such as torture and medical child abuse. When considering maltreatment, providers should be adept at obtaining a thorough history not only from the parent but when appropriate also from the patient. The most common form of child maltreatment is neglect, which encompasses nutritional and medical neglect, as well as other forms such as physical and emotional neglect. Talking with caregivers about stressors and barriers to care may give insight into the etiology for neglect and is an opportunity for the provider to offer or refer for needed assistance. Familiarity with injury patterns and distribution in the context of developmental milestones and injury mechanisms is critical to the recognition of physical abuse. While most anogenital exam results of child victims of sexual abuse are normal, knowing the normal variations for the female genitalia, and thereby recognizing abnormal findings, is important not only forensically but also more importantly for patient care. Pattern recognition does not only apply to specific injuries or constellation of injuries but also applies to patterns of behavior. Harmful patterns of behavior include psychological maltreatment and medical child abuse, both of which cause significant harm to patients. As health professionals serving children and families, pediatric providers are in a unique position to identify suspected maltreatment and intervene through the health care system in order to manage the physical and psychological consequences of maltreatment and to promote the safety and well-being of children and youth by making referrals to child protective services.

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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