New York State Child Abuse, Maltreatment, and Neglect

Etiology

Module 2: Understanding Trauma and Adverse Childhood Experiences 

Trauma is an intense event that threatens a person's life or safety in a way that is overwhelming for the mind to handle and leaves the person powerless. Trauma can bring about physical reactions such as rapid heart rate, tense muscles, or shallow breathing. Common traumatic events include going through or witnessing family violence, sexual abuse, emotional abuse, or violence in the community. For many parents, having a child removed from the home and dealing with the child welfare system are traumatic events.

Adverse childhood experiences 

Adverse childhood experiences (or ACEs) are negative experiences that occur during childhood. Research has shown that ACEs can have lasting impacts on physical, emotional, and mental health throughout a person's life.[Adverse Childhood Experiences in NYS] Research shows ACEs are common in all socioeconomic groups. Approximately 61% to 67% of the population in the United States has experienced at least 1 ACE. Children who have experienced numerous adverse experiences have higher rates of negative health outcomes, including depression, obesity, substance use, anxiety, heart disease, and early death. Other factors can intensify the effects of ACEs, including poverty, racism, generational trauma, and frequent unintended or indirect discrimination. Child maltreatment and abuse are adverse childhood experiences. 

Toxic stress occurs when a person experiences severe, prolonged adversity without adequate support. Toxic stress means that the stress response is continuously activated in the body. Toxic stress impacts children developmentally or behaviorally.

Trauma-informed practice

Trauma-informed practice is a model for engaging with individuals and families that recognizes the impact and influence trauma may have on individuals and families. The goals of a trauma-informed practice are to avoid the inadvertent retraumatization of individuals through interactions and to understand that trauma may have an impact on a person's behavior. Trauma-informed practice helps clinicians identify when past experiences or trauma may impact their clinical evaluation. 

Impacts of trauma

The work of mandated reporters is often affected by trauma. Trauma may impact the child or family that clinicians interface with, and trauma could affect clinical decision-making. ACEs and trauma alone may not rise to the level of child abuse or maltreatment, and the impact on the child should be assessed. The goal is to reduce the effects of ACEs while supporting children and families and increasing protective factors.

Additional resources include the following: 

• National Child Traumatic Stress Network
• National Center for PTSD
• Parents Anonymous
• Center for the Study of Social Policy
• Prevent Child Abuse NY
• New York State Trauma–Informed Network

Module 3: Understanding and Reducing Implicit and Explicit Bias

As humans, biases are normal, whether implicit or explicit, and affect our beliefs, decisions, and actions. Bias are personal and sometimes unreasoned judgments against a person, place, or thing. Biases may influence our decision-making, including how a person looks, sounds, and where they live. An implicit bias is a bias or prejudice that is present but not consciously held or recognized, so most people are unaware. An explicit bias is a personal and unreasoned judgment about a person, place, or thing on a conscious level.

Both implicit and explicit bias can appear as prejudice, discrimination, or oppression on individual, group, or systemic levels. Individual biases are deeply entrenched and are born out of a long history rife with unequal treatment of different social groups, discrimination and oppression, cultural conditioning, individual upbringing, and stereotypical portrayals of social groups. Decisions rooted in biases often significantly impact individuals, social groups, and communities. One of the benefits of being aware of the potential impact of personal biases is to take a proactive role in reducing how they impact clinical decision-making.

Understanding the impact of implicit bias on child welfare

National research shows, and NYS Office of Children and Family Services (OCFS) data confirms that disparities exist throughout the child welfare system presently and historically. OCFS Disproportionate Minority Representation data shows a historical overrepresentation of children and families of color in the child welfare system. Families of color are more likely to be involved in a report to the SCR. Children of color are more likely to be placed in foster care and generally experience slower achievement of permanency goals.

Research shows that the income status of families is a significant predictor of involvement with the child welfare system. Poverty in and of itself does not equate to child abuse or maltreatment. Research shows that families investigated by Child Protective Services (CPS) have several poverty-related risk factors, such as unemployment, single parenthood, food insecurity, housing stability, or lack of access to childcare. Families living below the poverty line are 3 times more likely to be substantiated for child maltreatment. This disparity has long-lasting and devastating impacts on both families and communities.

A mandated reporter's decision on whether to call the SCR can change the course of the life of a child and the members of a family. Awareness of the propensity for implicit or explicit bias and intentionality about making decisions should be connected to remaining objective before filing the report. Part of this process is to increase awareness regarding personal beliefs, including those hidden or unconscious. Supporting a family is possible without having to report a family. Approaching the responsibility as mandated reporters with empathy, compassion, care, and curiosity is paramount. Consider if the family's needs are met through other means outside of the CPS system. Given systemic distrust in such sensitive situations, these alternative recommendations can be pursued.

Strategies to reduce implicit bias

The first step in unraveling implicit bias is understanding the lens utilized to view the world. Bias can be present in various ways. Bias might look like subconscious thoughts (implicit), conscious thoughts (explicit), stereotypes, or inaccurate judgments. Bias can be unlearned. A proven strategy to reduce bias is to examine whether the factors of the situation would lead a clinician to the same decision to call the SCR if the child's or family's demographic information differed, including the child or family's:

• Race
• Ethnicity
• Gender
• Gender identity
• Sexual orientation or expression
• Religion
• Immigration status
• Primary spoken language
• Culture
• Age
• The neighborhood where they reside
• Presence of a disability
• Occupation
• Socioeconomic status of the family

If any of the above factors is answered yes, bias may impact the decision to call the SCR.

Critical thinking to reduce bias

Critical thinking is the best tool to reduce bias. As mandated reporters, clinicians should utilize critical thinking when deciding whether to call the SCR, including:

1. Identifying specific concerns about the current situation
2. Gathering adequate information about the current situation
3. Analyzing that information to separate facts from assumptions
4. Recognize the possibility of bias in personal opinions
5. Developing multiple hypotheses that could explain the situation
6. Determining whether the clinician is legally required to call the SCR and, if not, whether an alternative option is better, eg, connecting the individual or family to appropriate services in their community

Approach the situation with humility, recognize that we do not know everything about the situation and the family, be open and willing to learn, and consider information that might differ from our first impressions and assumptions. Harvard University developed the Implicit Association Test (IAT), which measures attitudes and beliefs that preclude a report.[Implicit Association Test]

Module 4: Mandatory Reporters

Mandated reporters are required by law to call the SCR when, in their professional role, they develop a reasonable cause to suspect a child younger than 18 is being maltreated or abused by a parent or person older than 18 who is legally responsible for the care of the child at the relevant time. A professional role is working or volunteering in a role requiring specific licensure or certification.

Reasonable cause to suspect

A "reasonable cause to suspect" occurs when the observations, combined with professional experience or training, lead to the belief that a child has been or is being maltreated or abused. A reasonable suspicion does not require proof a child has been maltreated or abused. One indicator or several indicators in combination may cause a clinician reasonable suspicion. Poverty, in and of itself, does not equate to maltreatment or abuse.

Person legally responsible

The term "person legally responsible" (PLR) includes the child's custodian, guardian, and any person responsible for the child's care at the relevant time. The term custodian may include any person continually or at regular intervals found in the same household as the child when the conduct of such person causes or contributes to the abuse or maltreatment of the child.[4] 

Confidentiality

State law provides confidentiality for mandated reporters and all sources of child abuse and maltreatment reports. However, CPS or the SCR may be required to provide the identity of the source of the CPS report in very limited circumstances and only as described in the law.[NYS Mandated Reporter Resource Center] The legal obligation to report suspected child abuse and maltreatment under NYS law supersedes client-patient confidentiality provisions. The Health Insurance Portability and Accountability Act (HIPAA) contains specific provisions allowing healthcare professionals to report information to the SCR, including personally protected, otherwise confidential health information.

Liability and immunity

The law gives all mandated reporters immunity from criminal and civil liability whenever a mandated reporter makes a report because they had a reasonable cause to suspect child abuse or maltreatment. The law presumes mandated reporters make such reports in "good faith" and, therefore, mandated reporters are protected, though CPS finds no evidence of abuse or maltreatment. A mandated reporter who fails to call the SCR when they have a reasonable suspicion of child abuse or maltreatment while in their professional role may be subject to criminal and civil liability. The mandated reporter may also be held civilly liable for any harm a child suffers due to their failure to call the SCR.

No employer or organization is permitted to require approval before calling the SCR. The legal obligations of a mandated reporter are personal, and the organization may not impede calling the SCR. All employers and organizations are also prohibited from retaliating for fulfilling the duties of a mandated reporter. The law does not require multiple reports on the same incident from the same organization.

Child abuse or maltreatment risk factors

Risk factors that increase child abuse and maltreatment include:

• Alcoholism and substance abuse
• Community violence
• Children aged younger than 4
• Family disorganization, dissolution, and violence
• Family history of child abuse and maltreatment
• Intellectual disability
• Lack of understanding of development and needs
• Limited education
• A large number of dependent children
• Low income
• Mental health issues
• Parenting stress
• Parental emotions that tend to justify maltreatment
• Physical disability or illness
• Poor parenting skills
• Social isolation
• Single parenthood
• Transient caregivers
• Young age
• Unemployment rates
• COVID-19 [5] 

Protective or preventive factors

Factors that are associated with a reduced risk of child abuse and maltreatment include:

• Family support
• Parental concern
• Parental education regarding child development and parenting
• Social support
• Parental resilience [6][7][8][CDC Risk and Protective Factors]

Potential long-term sequela of child abuse

Long-term sequela of child abuse and maltreatment include:

• Physical and mental health conditions
• Low life potential
• Premature death
• Substance abuse [4][9]

Epidemiology

Each year, over 3 million children are investigated nationally by CPS for child abuse and neglect. Of those, 20% have evidence of maltreatment.[10] Over 150,000 referrals for abuse and neglect are made in NYS, with nearly half confirmed as victims. Male and female percentages of victims are similar. The highest risk of abuse and neglect is in children younger than 3 years and African American and Native American children. Of those abused, approximately 75% are neglected, 15% to 20% are physically abused, and 5% to 10% are sexually abused.[4][9][11]

History and Physical

Module 5: Defining Maltreatment and Abuse

Parents and persons legally responsible (PLRs) for caring for a child in NYS must provide their children with the minimum degree of care. The minimum degree of care means that parents must provide their children with adequate food, clothing, shelter, medical care, education, and supervision, and they must refrain from excessive corporal punishment. Adequate medical care includes basic dental care, mental health services, and treatment for drug or alcohol misuse. The minimum degree of care regarding adequate food, clothing, shelter, and medical care must be considered, including whether the parent or PLR could do so or was offered other financial or reasonable means.

Adequate education means parents must ensure the children are actively enrolled. Actively enrolled in school does not mean a child has to earn high grades, participate in activities, or have impeccable attendance. The minimum degree of care regarding adequate education is measured by looking at the parent's conduct after considering any previous efforts by the school or CPS.

Adequate supervision is determined by whether a child can be safely left alone and is made on a case-by-case basis. No provision in NYS law or regulation dictates how old a child must be to be left alone without adult supervision. A child left alone in a residence or the community must demonstrate that they have the knowledge and skills to respond to a potential emergency properly and care for themselves. 

NYS law permits parents to use corporal (physical) punishment to discipline their children but within reasonable limits. Excessive corporal punishment includes the following:

• The child lacks the capacity to understand the corrective quality of the discipline.
• A less severe method is available and likely to be effective.
• The punishment is inflicted due to the parent's rage.
• The child receives injuries or bruises as a result.
• The length of punishment surpasses the child's endurance.

Maltreatment

Under NYS law, a child is maltreated when any of the following are present:

1. A parent or other person legally responsible for the child fails to provide the minimum degree of care, and that failure results in impairment or imminent danger of impairment to the child's physical, mental, or emotional condition.
2. A parent or other person legally responsible for the child causes a nonaccidental, serious physical injury to the child. Actual impairment or harm is not required to meet these criteria. Poverty in and of itself is not maltreatment.

Abuse

Under NYS law, a child is abused when any of the following are present:

1. A parent or person legally responsible for a child inflicts (or allows someone else to inflict) a nonaccidental serious injury that causes a substantial risk of death, serious or protracted disfigurement, protracted loss, or impairment of the function of any bodily organ.
2. A parent or person legally responsible for a child creates (or allows to be created) a substantial risk of nonaccidental physical injury, which would be likely to cause death, serious or protracted disfigurement, or protracted loss or impairment of the function of any bodily organ.
3. A parent or person legally responsible commits (or allows someone else to commit) a sex crime against a child.

Module 6: Indicators of Child Maltreatment and Abuse

Physical indicators of child maltreatment and abuse include the following:

• Unexplained bruises, fractures, burns, welts or lacerations
• Suspicious injury or bruising, including where:
  • The location of the injury may be atypical
  • The explanation provided for the injury doesn't match the pattern of injury
  • The bruise or laceration is shaped like an object (eg, a handprint or looped cord)
• Unattended physical problems, medical or dental needs
• Pain or itching in the genital area
• Lags in physical development or growth

Behavioral indicators of child maltreatment and abuse include the following:

• A child is not acting like they normally do
• Acting oddly shy or attention-seeking
• A sudden drop in grades or lack of interest in activities
• Engaging in self-destructive behaviors
• Isolating from peers
• Begging for or stealing food
• Consistent fatigue or falling asleep in class
• Lingering in school due to reluctance to go home
• Use of alcohol or illegal drugs
• Infrequent school attendance
• Sudden new sexual behavior or knowledge that is inconsistent with the child's development, age, circumstances, or past behaviors

Do not view indicators in isolation but in context within the clinical presentation. The following should be considered when indicators of abuse are noted:

• Each indicator must be considered in relation to the child's current age, circumstances, and physical condition or behavior.
• The first step in addressing a presenting concern is determining if an explanation is consistent with the observed physical and behavioral indicators.
• Abuse or maltreatment should never be assumed.
  • Consider previous clinical encounters with this child and see if a difference is apparent in the current clinical encounter.
  • Making an objective assessment free from any implicit or explicit bias is critical.

Virtual environment

Mandated reporters may interact with children in a virtual environment. For example, children may attend school remotely, visit doctors using telemedicine, and participate in therapy sessions on virtual platforms. If interacting with children in a professional role, the responsibilities of a mandated reporter are the same as in a virtual environment. When assessing safety virtually, clinicians should perform the following where possible:

• Be alert if a child is trying to communicate something to you without someone else in the room noticing.
• Note if a child's demeanor or behavior is different when someone else enters the room.
• Listen for statements a child makes concerning you, siblings, or their peers.
• Try to observe the child's body language and any signs of injury.
• Evaluate for a depressed or anxious affect.
• The following logistics are recommended when clinicians are assessing children virtually:
  • Use reliable technology with adequate lighting and sound.
  • Make sure the child is present for at least part of the visit.
  • Make sure to have everyone introduced who is in the room with the child or who enters the room after the visit starts.
  • Ask for enough privacy for the child and parent to discuss sensitive matters. This may mean asking nonparticipating household members to move to a different room.
  • Confirm the physical location in the event you need to contact emergency services.
  • Observe, verbalize what you see, and ask if the family agrees.
• Clinicians should be sure to perform the following:
  • Provide clear communication channels. The preferred channels are email, phone, chat, text, or online tools.
  • Pay attention to nonverbal cues. Note if a child's demeanor or behavior is different when someone else enters the room.
  • Be alert if a child turns off a webcam or hesitates to use one.
  • Look at the environment and note any unsafe conditions.
  • Assess if appropriate supervision is available for the child.
  • Note if young children are watching younger siblings.[12]

Types of Abuse and Neglect

Physical neglect, emotional neglect, emotional abuse, and sexual abuse are types of abuse and neglect. Physical neglect is the most common form of abuse. This type of abuse is the failure to provide a child with adequate food, shelter, clothing, education, hygiene, medical care, protection from hazards in the environment, basic needs, or supervision needed for normal growth and development. Physical abuse of a child includes any nonaccidental physical injury of a child inflicted by a parent or a caretaker resulting in or risking serious disfigurement, impairment of physical or emotional health, and loss of bodily function or death. Physical abuse includes beating, burning, biting, shaking, and excessive corporal punishment.[9]

Emotional neglect is the failure of a parent or caregiver to supply a child with the love and support necessary for healthy emotional development. Examples include failure to provide a child with warmth, attention, supervision, affection, praise, or encouragement. Emotional abuse is commonly defined as the nonphysical maltreatment of a child that can seriously interfere with his or her positive emotional development. Patterns of abusive behavior can include constant rejection, terrorizing, exposing a child to corruption, violence or criminal behavior, irrational behavior, and verbal abuse (eg, excessive yelling, belittling, and teasing). Emotional abuse has the potential to cause serious cognitive, affective, or other behavioral health problems.

Physical neglect

Physical examination may not only demonstrate signs of physical abuse but may show signs of neglect. The general examination may show poor oral hygiene, extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds. Indicators of physical neglect include:

• Abandonment
• Drug withdrawal symptoms
• Delayed development
• Failure to thrive
• Hunger
• Inappropriate dressing
• Lack of supervision
• Poor hygiene 
• Truancy
• Unattended physical problems [9]

Emotional neglect

Behavioral indicators of neglect in a child include:

• Alcohol or substance abuse
• Begging or stealing food
• Chronic fatigue
• Conduct disorders and delinquency
• Developmental delay
• Extended stays at school
• Habit disorders
• Hysteria
• Hypochondria
• Inhibition of play
• Absence of a caretaker at home
• Obsessive-compulsive behaviors
• Overly compliant
• Overly demanding
• Passive-aggressive
• Phobias
• Runaway
• Sleep disorders
• Suicide attempt

Behavioral indicators of neglect in a legally responsible person include:

• Blaming the child for problems
• Inconsistent treatment
• Lack of caring
• Continued rejection
• Treating children unequally

Factitious disorder imposed on another, or Munchausen syndrome by proxy, is a form of child abuse. This syndrome typically occurs when a caretaker falsifies an illness in the child to gain attention. No obvious external monetary rewards usually exist. Typical findings in factitious disorder include:

• Deceptive behavior is evident in the absence of obvious external rewards
• Falsification of physical or psychological signs or symptoms
• History of many hospitalizations with unusual signs and symptoms
• History of unusual death or illness in the family
• Improves when hospitalized but worsens when returns home
• Lab samples do not match the child
• Unexplained by another mental disorder
• Presents another individual to others as ill, impaired, or injured
• Signs and symptoms do not agree with the test results
• Toxic or abnormal chemicals in the child's blood, stool, or urine
• Worsening of the child's symptoms by the perpetrator but not witnessed by healthcare professionals 

Educational neglect

Poor school attendance does not equate to a reasonable cause to suspect maltreatment. A report of suspected educational neglect should be called into the SCR to remedy excessive absences, but only as a last resort. School personnel should first try working with the student, family, and community agencies to identify needs and the resources available to meet those needs. All of the following elements must be present to warrant a call to the SCR for educational neglect:

• The child must be of school age and currently living in NYS
• The child must be excessively absent without a valid reason or excuse
• The child's education must be impaired due to the excessive absenteeism (or the child has an individualized education program and has missed necessary services due to excessive absenteeism)
• The parent or PLR has been made aware of excessive absenteeism and impairment by means other than simply sending a note home or leaving a voicemail message.
• School officials have made efforts to engage the child and parent or PLR
• No parent or PLR has taken any action to rectify the situation 

Residential neglect

A child is an unemancipated person aged younger than 18. In NYS, a child is also defined as a child residing in a group residential care facility under the jurisdiction of the New York State OCFS, Division for Youth (DFY), Office of Mental Health (OMH), Office of Mental Retardation and Developmental Disabilities (OMRDD), or the State Education Department (SED).

A child with a handicapping condition aged 18 or older (up to age 21) who is defined as an abused child in residential care and who is in residential care in any of the following facilities:

• New York State School for the Blind (Batavia, NY)
• New York State School for the Deaf (Rome, NY)
• A private residential school which has been designed for special education
• A special act school district or a state-supported school for the hearing or visually impaired that has a residential component

In NYS, the terms maltreatment and neglect may be used somewhat interchangeably. Maltreatment is used in social services law, and neglect is used in the Family Court Act. Maltreatment or neglect includes a child's physical, mental, or emotional impairment or imminent danger of impairment by the parent's or legal guardian's failure to exercise a minimum degree of care, including:

• In supplying the child with food, clothing, shelter or education, or medical, dental, optometrical, or surgical care, though financially able to do so or offered financial or other reasonable means to do so
• In providing the child with proper supervision or guardianship, by unreasonably inflicting or allowing to be inflicted harm, or a substantial risk thereof, including the use of excessive corporal punishment
• By misusing drugs or alcohol to the extent that he or she loses self-control of his or her actions
• By any other acts of a similarly serious nature requiring the aid of the court
• By abandoning the child

Additionally, a maltreated or neglected child is any of the following:

• Aged younger than 18 and is defined as a neglected child by the Family Court Act
• Has had serious physical injury inflection upon her or him by other than accidental means
• Aged 18 or older, is neglected, and resides in one of the special residential care institutions listed above under the definition of the child

According to the Family Court Act Section 1012, a "person legally responsible" includes the child's custodian, guardian, or any other person responsible for the child's care at the relevant time. A custodian may include any person, continually or at regular intervals, found in the same household as the child when the conduct of such person causes or contributes to the abuse or neglect of the child. The Social Services Act includes a maltreated child aged 18 or older who is neglected and resides in one of the special residential care institutions previously listed.

Abandoned Infant Protection Act

NYS Abandoned Infant Protection Act was enacted to save the lives of unwanted newborns. The act allows a parent to abandon a newborn baby up to 30 days of age anonymously and without fear of prosecution, provided the baby is abandoned safely with no physical harm to the baby. A parent is not guilty of a crime if the infant is left with an appropriate person or in a suitable location, and the parent promptly notifies an appropriate person of the infant's location. A hospital, staffed police, or fire station are safe and suitable choices. A person leaving an infant under this law is not required to give his or her name.[Abandoned Children and Protection Act] The person must intend to wholly abandon the baby by relinquishing responsibility for and rights to the care and custody of the infant.

What is considered a suitable location is not defined by law; however, hospitals, staffed police stations, and fire stations have long been considered suitable locations. Calling the local hospital, police station, fire station, or county attorney for suitable locations in the clinician's community is recommended. For information on safe places to leave an infant under the Abandoned Infant Protection Act, individuals may also call 1-866-505-SAFE (1-866-505-7233). Individuals who are deemed appropriate are also not defined by the law but may include a person in an applicable professional role or another responsible person in the location where the child is abandoned. 

Secure medical attention immediately if an infant is distressed or needs medical care. If no obvious medical problems exist, contact the county Department of Social Services (in New York City, the Administration for Children's Services) and inquire about an abandoned infant's care. If the local Department of Social Services does not have 24-hour staff coverage outside of normal business hours, contact the New York Statewide Central Register of Child Abuse and Maltreatment (child abuse hotline) at 1-800-342-3720. The hotline staff should notify the on-call child protective services staff, who takes custody of the infant.

Any abandonment of an infant is always reportable as suspected child abuse or maltreatment. Police officers, hospital staff engaged in the admission, examination, care, or treatment of patients, and all other mandated reporters are still required to fulfill their legal responsibilities as mandated reporters and report the abandonment. Mandated reporters should call the New York Statewide Central Register of Child Abuse and Maltreatment (child abuse hotline) at 1-800-342-3720, whether or not they have the name or identifying information for the infant or the person who abandoned the infant. The unknown parties will be listed on the report as unknown persons. A person who abandons an infant in a manner that complies with this law is not required to give his or her name. The Abandoned Infant Protection Act offers anonymity to encourage those people who abandon their newborn infants to do so in a safe manner. They can call the OCFS toll-free Abandoned Infant Helpline at 1-866-505-SAFE (7233) for referrals, information regarding "suitable locations" where a baby can be left, or contact information for their local social services department. Any mandated reporter who learns of abandonment must fulfill mandated responsibilities, though unsure of the name of the person abandoning the child.

This law was enacted in July 2000 and amended in August 2010. The amendments removed criminal liability for the crimes of abandonment of a child and endangering the welfare of a child when a parent, guardian, or other legally responsible person abandons an infant while meeting all of the following conditions:

1. The abandoned infant is no older than 30 days old.
2. The person who abandons the infant intends that the infant will be safe from physical injury and cared for appropriately.
3. The person leaves the infant with an appropriate person OR leaves the baby in a suitable location and immediately notifies an appropriate person of the infant's location.
4. The person must intend to wholly abandon the infant by relinquishing responsibility for and rights to the care and custody of the infant.

Signs and Symptoms of Child Abuse

Diagnosis of child abuse, neglect, or maltreatment may be difficult as the victim may be unable to provide information due to preverbal or nonverbal status, fear, or severe injuries. Also, the perpetrator rarely admits to the abuse, and witnesses are uncommon. Clinicians may see children of maltreatment in a variety of situations that include:

• An adult or mandated reporter brings the child in for evaluation when they are concerned about abuse.
• A child or adolescent comes in to disclose the abuse.
• A perpetrator brings the patient for medical care with concern that the abuse is severe.
• A child presents for care unrelated to abuse, and abuse may be found incidentally.

Physical abuse should be considered in the evaluation of all child injuries. A thorough history of the present illness is vital to making a correct diagnosis. Information about the child's behavior before, during, and after the injury should be obtained. History-taking should include the interview of the verbal child and each caretaker separately. The parent or caretaker should be allowed to provide their history without interruptions without being influenced by the clinician's questions or interpretations.

Pediatric physical abuse should be considered in the following:

• Injury in a nonambulatory infant
• Injury in a nonverbal child
• Injury inconsistent with the child's physical abilities
• A statement of harm from the verbal child
• Mechanism of injury not plausible
• Multiple injuries, particularly at varying stages of healing
• Bruises on the torso, ear, or neck in a child aged younger than 4
• Burns to genitalia
• Stocking or glove distributions or patterns of injury
• The caregiver is unconcerned about the injury
• An unexplained delay in seeking care
• Inconsistencies or discrepancies in the histories provided 

"TEN 4" is a useful mnemonic to recall which bruising locations are of concern in cases involving physical abuse: bruises of the torso, ear, or neck in a child younger than 4 years of age or any bruising in a child younger than 4 months of age concern for abuse. Other injuries that are highly suggestive of abuse include:

• Retinal hemorrhages
• Posterior rib fractures
• Classic metaphyseal lesions [4]

Physical Abuse Clinical Features

Pediatric abusive head trauma

Pediatric abusive head trauma (PAHT) or "shaken baby syndrome" is a common cause of abusive head injury in children and is associated with significant morbidity and mortality. PAHT is an injury to the intracranial contents or skull of an infant or young child inflicted by blunt impact or violent shaking. An evaluation may begin with a skull x-ray or head ultrasound but often requires a head computed tomography (CT) for definitive diagnosis, particularly in an emergency setting or in an unstable child. Common head CT findings in PAHT include subdural hematomas and diffuse axonal injury. The evaluation should also include an ophthalmologic examination to evaluate for retinal hemorrhages.

Signs and symptoms of PAHT are often nonspecific and may include:

• Absence of hair due to vigorous hair-pulling
• Apnea
• Bulging fontanelles
• Coma
• Decreased appetite
• Irritability
• Unexplained injury to the frenulum, jaw, nose, or teeth
• Lethargy
• Retinal hemorrhages
• Seizures
• Vomiting [9]

The long-term sequela of PAHT includes:

• Blindness
• Cerebral palsy
• Developmental delay
• Hearing loss
• Learning difficulties
• Seizures

Glutaric aciduria type 1 is a rare metabolic disease that can cause retinal hemorrhages and subdural hematomas and may be mistaken for PAHT.

Skeletal trauma

The majority of abusive fractures occur in nonambulatory infants and toddlers younger than 18 months of age. Any unexplained fracture in a child should raise suspicion of child abuse. The following fractures may be concerning for physical abuse:

• Skull fractures
• "Bucket handle" fractures or "corner" fractures due to twisting of the ends of the long bones
• Long bone fractures in a nonambulatory child
• Greenstick fractures
• Posterior or lateral rib fractures
• Scapular fractures other than those caused by birth trauma
• Spinal fractures
• Sternal fractures
• Multiple fractures in various stages of healing
• Facial fractures
• Skeletal trauma with other injuries

Symptoms that raise suspicion for fracture include:

• Red, swollen, painful joint or limb
• Patient crying with pain or irritability
• Local tenderness to palpation
• Unwillingness to move the limb

Organic causes of fractures that may be mistaken for child abuse include:

• Osteogenesis imperfecta
• Osteopenia
• Metabolic bone disease: Rickets, vitamin C, and copper deficiency
• Oncological disorders
• Ehlers-Danlos syndrome
• Injury sustained during resuscitation: rib fractures, internal organ contusions, retinal hemorrhages 

Abdominal trauma

Abdominal injury may result in significant morbidity and mortality. The most commonly injured organs are the spleen (over 60%), liver, pancreas, kidneys, and, less frequently, small bowel and bladder. Overt findings may not always be present. Rapid screening, such as the Focused Assessment with Sonography for Trauma (FAST), may assist in evaluating for acute injury along with laboratory tests, including amylase, lipase, liver function tests, and urinalysis. Any positive ultrasound or laboratory finding suggests the need for further evaluation or imaging, eg, an abdominal and pelvic CT scan.

Bites

Human bites appear as 2- to 5-cm oval or circular marks made by 2 opposing concave arcs, with or without associated ecchymosis.[13] Bitemarks can provide useful evidence in cases of physical assault of a child and can also be a source of the assailant's DNA. Measurement of the inter-canine distance of the bite may help distinguish between an adult's bite (3 to 4.5 cm), a small adult's bite (2.5 to 3 cm), or a child's bite (2.5 cm, a child's deciduous teeth). However, the data is not validated in clinical practice.

Bruising

A bruise is the most common soft tissue injury in cases of physical abuse. Bruises can be characterized by the following:

• Petechiae: Very small, pinpoint erythematous, non-blanching bruises caused by broken capillaries.
• Purpura: Small bruises occurring in groups or a single bruise up to 1 cm
• Ecchymoses: Larger bruise >1 cm. 

Bruising in nonabused children is most commonly found on the knees, shins, and bony prominences. Bruising in nonambulatory children is uncommon and is concerning for nonaccidental trauma. Commonly, in abuse, bruises are found on the backside of the child, beginning at the neck and continuing down to the knees, including the shoulders and the child's arms. This area has been called the child's "primary target zone." The following pattern of bruises is potentially worrisome:

• Clustered or patterned
• Inconsistent with history
• Large or numerous
• Present in various stages of healing
• Present in nonambulatory children

A pediatrician needs to differentiate bruises from "pseudo-bruises," including Mongolian spots (grey-blue, can be found anywhere on the body with clear-cut margins), maculae cerulae (bluish spots on the skin due to pubic lice), and allergic shiners (more brown than blue, may be confused with black eyes). Bleeding disorders, vasculitides, hypersensitivity syndromes, and various cultural practices such as spooning, coining, and cupping are also included in the differential diagnoses for bruises. 

Burns

Burns are often accidental and can lead to significant morbidity and mortality in children. Burns that cannot be explained by history, that present with a considerable delay in seeking care, have characteristic sharp lines of demarcation (also called the line of immersion), or have a symmetric pattern are concerning for child abuse. Other typical burns for child abuse include:

• Immersion burns, eg, doughnut burns (as buttocks make firm contact with the base of a container) or zebra burns (a child immersed in a flexed position with spare the creases of the child's body giving a striped configuration)
• Glove-like or sock-like burns from immersion of child's feet and hands
• Dry contact burns patterned like a household appliance, eg, an iron, stove, heater, grate, radiator pipe, hot plate, or curling iron
• Round cigarette burns
• Rope burns

The differential diagnoses of burns include:

• Chemical and irritants, eg, bleach, complementary and alternative therapies
• Infections including impetigo, blistering distal dactylitis, ringworm
• Stephens-Johnson Syndrome or toxic epidermal necrolysis
• Dermatological conditions (eg, diaper dermatitis)
• Scalded skin syndrome

Lacerations

Lacerations are a pattern of injury in which skin and the underlying tissues are cut or torn. Unexplained lacerations in the arms, eyes, genitalia, gums, legs, lips, mouth, and torso are potentially concerning.

Behavioral signs of physical abuse 

In addition to the history and physical examination, observation of the child's behavior and the child-caregiver interactions during the encounter can provide clues to the potential for physical abuse. Behavioral indicators of abuse in children include:

• Aggressive, destructive, or disruptive behavior
• Apprehensive when other children cry
• Compulsions, hypochondria, phobias, and obsessions
• Fear of going home
• Fear of caregiver
• Emotionless, passive, or withdrawn
• Habit disorders
• Lack of interest in activities for age
• Overly seeks affection
• Self-injurious behaviors
• Suicide attempts
• Return of bedwetting
• Unexpected sexual knowledge for age
• Unwilling to change clothes for physical education or sports
• Wearing concealing clothing

Behavioral indicators of abuse in caregivers include:

• Alcohol or drug abuse
• Concealment of injuries
• Disciplines harshly
• Describes child as evil
• Delays medical care
• History of abuse as a child
• Lack of emotional control
• Lack of parenting skills
• Lack of support network
• Multiple clinicians
• Overly protective or jealous
• Poor self-esteem
• Unconcerned about child's health or well-being
• Unclear or conflicting explanation of the child's injury
• Uses the child to meet emotional or physical needs
• Unrealistic expectations

Sexual Abuse Clinical Features

Sexual abuse is the involvement of dependent, developmentally immature children in sexual activities that they do not fully comprehend, to which they are unable to give consent, or that violate the social taboos of family roles.[11] Sexual abuse and maltreatment include situations in which the parent, caregiver, or another person legally responsible for a child aged younger than 18 commits or allows to be committed any of the following actions:

• Touching a child's mouth, genitals, buttocks, breasts, or other intimate parts for gratifying sexual desire; or forcing or encouraging the child to touch the caregiver or other person legally responsible in this way for gratifying sexual desire
• Engaging or attempting to engage the child in sexual intercourse or sodomy
• Forcing or encouraging a child to engage in sexual activity with other children or adults
• Exposing a child to sexual activity or exhibitionism for sexual stimulation or gratification of another
• Permitting a child to engage in sexual activity that is not developmentally appropriate and when such activity results in the child suffering from emotional impairment
• Using a child in a sexual performance, eg, a photograph, play, motion picture, or dance, regardless of whether the material itself is obscene

In addition, giving indecent material to a child is a crime. Sexual abuse and maltreatment include such criminal offenses as rape, sodomy, other nonconsensual sexual conduct, and prostitution.

Sexual behaviors are rare in infants except for hand-to-genital contact. Sexual behaviors are more prevalent in children aged 2 to 5 as the child becomes aware of their body parts; sexual behaviors become less common in children older than 5 years as the child becomes aware of social rules. However, if a child has inappropriate behaviors, eg, an older child touching other children's genitals, undressing in front of others, and looking at others undressing, a concern should exist.

A normal physical examination does not rule out sexual abuse, and the most common finding in sexual abuse is a normal physical examination. In most cases, evidence that sexual abuse has occurred is based on the child's statement. Suspicion should be raised if any of the following are present:

• Alcohol and drug addiction
• Adolescent pregnancy
• Agoraphobia
• Alopecia areas
• Anogenital trauma
• Anxiety
• Bruises
• Burns
• Bloody or torn underwear
• Bruises on the palate
• Depression and suicidal thoughts
• Diseases that are untreated or not diagnosed
• Fractures
• Head injuries
• Lacerations
• Ligature injuries
• Malnourishment
• Painful urination and bowel movements
• Painful sitting or walking
• Panic attacks
• Poor hygiene
• Posttraumatic stress disorder (PTSD)
• Recurrent urinary tract infections
• Sexually transmitted diseases and pelvic infections

Epidemiology of sexual abuse

Recognizing sexual abuse can be difficult as physical evidence may be overlooked or absent. Considerations that should be kept in mind include:

• Every culture, class, and race is at risk.
• Boys are less likely to report their victimization.
• Children may be reluctant to disclose abuse by a family member or friend.
• A young child may not have the language skills to describe events.
• Girls are sexually abused more often than boys.
• Perpetrators are more commonly male.
• Most perpetrators are known to the victim.

No average profile of a child molester or victim is apparent.

Long-term effects of sexual abuse include:

• Anxiety
• Difficulty concentrating
• Depression
• Self-injurious behaviors
• Substance abuse
• Suicide [14]

Sex trafficking 

The Trafficking Victims Protection Act defines "severe forms of trafficking in persons" as (a) sex trafficking in which a commercial sex act is induced by force, fraud, or coercion or in which the person induced to perform such an act has not attained 18 years of age; or (b) the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for subjection to involuntary servitude, peonage, debt bondage, or slavery. Commercial sex act means any sex act on account of which anything of value is given to or received by any person. 

Clinicians should be cognizant of the following regarding sex trafficking:

• The average age of sex trafficking victims is 11 to 14.
• Sex trafficking frequently starts on the internet.
• The number of victims worldwide is in the millions, and half of the affected individuals are children.
• Women are more commonly affected than men.[15] 

If sex trafficking is suspected, complete the physical examination in private, then consider the screening questions (see Image. Assessment for Human Trafficking).[11]

Mandated Reporters for Child Abuse 

All clinicians are mandated reporters, and as such, they are required to report to child welfare when reasonable suspicion of abuse or neglect exists. A clinician does not need to be certain but does need to have a reasonable suspicion of the abuse. This mandated report may be lifesaving for many children. An interprofessional approach to the evaluation with the inclusion of a child abuse specialist is optimal.

Forensic Evidence of Child Abuse

If child abuse or neglect is considered, the history and physical examination findings may be used in legal proceedings. Photographs, diagrams, and detailed findings are helpful for recall at trial. Findings should be reported accurately and without bias.

Photographic evidence

New York Social Service Law allows any person or official required to take evidence of suspected abuse to take color photographs of visible trauma or radiographs. The images should be provided to CPS as soon as possible. Consent is not needed for a minor child to be photographed if child abuse is suspected and reported to the SCR. A chain of custody should be maintained. The institutional protocol for releasing photographs should be followed.

The following recommendations should be utilized when taking photographs:

• Include the child's name, date of birth, medical record number, date and time of photographs, and name of the clinician on an index card.
• Take photos at various ranges: distant, mid-range, and close-up.
• Use adequate lighting.
• Include anatomic landmarks to identify the location of findings.
• Use a ruler placed on the skin to document the size of any findings.
• Photograph the child's face and body to identify the patient.

Victim disclosures

If a child discloses abuse, they may only disclose part of what happened. Clinicians should document in the child's own words, quoting the child if possible, and avoid rushing the child or making promises the clinician cannot keep. The child should also be informed that they may need to repeat the information. Methods to enhance disclosure include:

• Ask who, what, where, and when.
• Ask open-ended questions.
• Avoid expressing emotion.
• Be a good listener.
• Remain calm.
• Thank them for talking.
• Use age-appropriate language.

Additionally, disclosures that may be indirect hints of abuse include:

• Admitting to a problem but being unwilling to share
• Stating an individual (eg, my father, mother, brother, or sister) would not let me sleep
• Stating an individual (eg, my uncle, aunt, cousin, and babysitter) keeps bothering me

Evaluation

Laboratory Tests

Laboratory evaluation may be performed to evaluate for other diseases as the causes of the injury, including:

• Complete blood count (CBC) to assess for anemia and thrombocytopenia
• Coagulation profile including prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT)
• Metabolic panel, eg, glucose, BUN, creatinine, albumin, protein
• Liver function studies, eg, AST, ALT
• Amylase and  lipase
• Bleeding diatheses studies, eg, von Willebrand antigen, von Willebrand activity, factor VIII, factor IX, and platelet function assays
• Calcium, magnesium, phosphate, and alkaline phosphatase to evaluate for bone disorders

Radiology Studies

Any child younger than 2 years for whom a concern regarding physical abuse exists should have a complete skeletal survey obtained as part of the evaluation. Additionally, any sibling younger than 2 years of an abused child should also have a skeletal survey performed. A skeletal survey consists of 21 dedicated x-rays, as recommended by the American College of Radiology. The views include the skull, spine, chest/ribs, pelvis, femur, leg, foot, humerus, forearm, and hand. If the findings are abnormal or equivocal, further dedicated x-rays of the area of concern or follow-up x-rays are indicated in 2 weeks to evaluate for healing fractures. The most common differential diagnosis of nonaccidental injury is an accidental injury.[4][9][16][17]

Treatment / Management

Initial management of an abused child involves stabilization, including assessing the patient's airway, breathing, and circulation. Once the patient is stable, a complete history and physical examination are required. With the suspicion of any form of child abuse, CPS needs to be informed. Current recommendations suggest consulting a pediatrician or pediatric emergency clinician before proceeding with a report.[18][19] 

The involvement of a child abuse specialist is essential for optimal evaluation and management. If the patient is seen in an outpatient setting, transfer to an emergency department for laboratory and radiologic evaluation, and the appropriate continuation of care may be indicated. If a child is transferred to another clinician or facility, the initial clinician caring for the patient is responsible for reporting the case to CPS. The treating clinician is responsible for recognizing potential abuse, not identifying the perpetrator. The clinician should continue to advocate for the child, ensuring that the patient receives the appropriate follow-up care and services.

Victims of sexual abuse should have their physical, mental, and psychosocial needs addressed. Baseline sexually transmitted infection (STI) and pregnancy testing should be performed, and empiric treatment for HIV, gonorrhea, chlamydia, trichomonas, and bacterial vaginosis infection for adolescent victims should be offered. Also, emergency contraception to prevent unwanted pregnancy is most effective if given within 72 hours but may be offered up to 5 days after unprotected intercourse. Prepubertal patients are not provided with prophylactic treatment due to the low incidence of STIs in this age group. Urgent evaluation can prove extremely beneficial for patients needing prophylactic STI treatment, emergency contraception, managing anogenital injury, collecting forensic evidence, urgent child protection, or urgent care for suicidal ideation.[4][9][11][20]

Differential Diagnosis

The differential diagnoses for abuse depend on age, injury type, and signs and symptoms. The evaluation of an injury should differentiate between accidental and inflicted trauma. An astute clinician must carefully consider organic disease processes or accidental injury versus deliberately inflicted trauma, which include:

• Accidental asphyxia
• Accidental bruises 
• Accidental fractures 
• Accidental burns
• Accidental head injury 
• Arteriovenous malformations 
• Atopic dermatitis
• Bleeding or hemorrhagic disorder
• Birth trauma
• Caffey disease
• Chemical burn
• Coining
• Congenital syphilis
• Contact dermatitis
• Cupping
• Erythema multiforme
• Factitious disorder
• Hemangioma
• Henoch-Schönlein purpura
• Hypervitaminosis A
• Immune thrombocytopenic purpura
• Impetigo
• Inflammatory skin conditions 
• Insect bites
• Osteogenesis imperfecta
• Osteomyelitis
• Osteopenia
• Malignancy
• Meningitis
• Menkes disease
• Metabolic disease
• Mongolian spots
• Nevi
• Phytophotodermatitis
• Rickets
• Scurvy
• Sunburn
• Valsalva-induced subconjunctival hemorrhage

Prognosis

Module 7: Learning Exercises

The following are examples to help highlight the complexities of managing a case of suspected child abuse or neglect:

Exercise 1

Suppose a child under the age of 18 undergoes excessive physical beating when he does not adhere to the wishes of his caregivers, for example, if and when the child arrives late from school back to his home. The same child, though undergoing physical harm, also tends to plan his meals, sometimes has the help of classmates to obtain food throughout the schooldays, and does not have role models within his family structure to help him with homework. If and when asked about where he could potentially nurture an interest in sports, his caregivers have no idea, so he has to rely primarily on his teachers, classmates, and friends from his neighborhood. However, his caregivers, who consist of his biological mother and stepfather, are struggling financially. In this scenario, which preexisting risk factor is not a form of maltreatment?

The following issues should be considered:

• Physical beating is a form of maltreatment, especially if in response to a lack of adherence to his caregivers' rules and excess consequences disproportionate to his actions.
• If the child is unsupervised within his home environment, this is a form of maltreatment.
• Since his emotional well-being depends on being able to nurture interests, his guardianship at home is inadequate, and this is also a form of maltreatment.

The financial circumstances of his caregivers may or may not be in the child's control and may influence his ability to succeed. If this circumstance is not in the caregivers' control, it is not a form of maltreatment. Clinicians must remain cognizant of what they deem maltreatment before involving CPS.

Exercise 2

Suppose a child under the age of 18 arrives at the emergency department with spiral fractures of the left humerus, bruising to the abdomen and inguinal areas, and appears lethargic, with a flat affect, unable to respond to questions about her day. She shares that she is a competitive equestrian, and recently, she has been training between 6 to 8 hours a day for an upcoming competition. As a clinician, you consider within your differential diagnoses child abuse, given her clinical presentation. Additionally, given her age, gender, and areas of bruising, you suspect sexual abuse. What additional information may be needed from a complete patient history?

Clinicians should consider the following issues:

• If the patient arrived with a caregiver, talking to the caregiver would provide context for the patient's situation. If the patient appears comfortable within the caregiver's presence, and the caregiver shares that the patient has a competitive personality and has not been eating or sleeping lately, this is pertinent information.
• If no prior admissions to the emergency department are documented when looking into the patient's medical history, this visit could be a one-time occurrence that does not require a call to SCR.
• If, on further evaluation, the patient has been ingesting medications, eg, steroids, laxatives, or diuretics, this would lead to a separate evaluation. 

Critical thinking in such presentations ensures that clinicians do not jump to conclusions about child abuse but rather try to understand the context of 1 clinical encounter. Making such a report does have impactful consequences for a child, and clinicians must gather and integrate pertinent information before deciding to call SCR. In such scenarios, communicating with a patient's pediatrician may provide a better context.

Exercise 3

A child has recently had questions about their gender and is undergoing an evaluation for gender dysphoria with the school health center. Recently, the child has wanted to be referred to as "they" as an identifying pronoun. The child has lacked attendance on and off from school for the past 2 weeks, and teachers cannot contact the child's parents. This student is historically seen playing alone and eating alone and has shared with the school counselor that people pick on them as different. Several of the child's classmates have verbally commented about this child's appearance. The principal has contacted the school counselor to discuss addressing the student's lack of attendance. What is the school counselor's next best step?

The following issues should be considered:

• Calling SCR immediately may exacerbate the situation since the child is already under a lot of emotional stress.
• Involving classmates who seem to be bullying the child may also exacerbate the situation since they may provide conflicting information.
• Involving law enforcement without engaging the family further may lead to additional distrust, worsening the student's isolation.

As the student's counselor, reaching out to the family or considering the possibility of a home visit is a good next step. Speaking with the child's teachers and any relevant school staff could also provide context. Additionally, reviewing the student's file to consider where they go when they feel stressed, ie, the local library or their favorite mall, is essential to understand how to support this child. If these initial measures fail, the above options could be considered next.

Complications

Complications include the following:

• Fractures
• Burns
• Disfigurement
• Emotional trauma
• Seizures
• Psychosis (brief or repeated episodes)
• Hallucinations
• Suicide attempts

Long-term effects include the following:

• PTSD
• Schizophrenia
• Bipolar disorder
• Major depressive disorder [14]