Child Maltreatment

What is child maltreatment?

Child maltreatment is any intentional harm to a child. Child maltreatment includes neglect and abuse.

• Neglect is when parents or caregivers fail to ensure a child's health and well-being. Neglect may result from not providing a child with appropriate shelter, schooling, clothing, medical care, or protection from hazards. Child neglect is just as serious as abuse and is more common than abuse. However, it is not unusual for a victim to be both neglected and abused.
• Physical abuse causes bodily injuries, such as cuts, bruises, burns, broken bones, punctures, or damage to internal organs. Physical abuse can also harm a fetus, such as when a pregnant woman has substance abuse problems or is injured as a result of domestic violence.
• Psychological abuse is a pattern of intentional verbal or behavioral actions or lack of actions that convey to a child the message that he or she is worthless, flawed, unloved, unwanted, endangered, or only of value to meet someone else's needs. Withholding emotional support, isolation, or terrorizing a child are forms of psychological abuse. Domestic violence that is witnessed by a child is also considered a form of psychological abuse.
• Sexual abuse is any act with a child that is intended to sexually gratify an older child or adult. Sexual abuse is any sexual activity that a child does not comprehend or consent to or that is against the law. Exhibitionism, voyeurism, and exposing a child to pornography are types of sexual abuse. Sexual abusers can be young or old, male or female, and usually are family members (incest) or acquaintances of the child. Sexual abuse by a stranger is relatively rare. Sexual play is not sexual abuse. Sexual play is normal behavior between preadolescent children who are not separated by more than 4 years of age and does not involve any type of power, force, or coercion. Sexual play occurs when children look at or touch each other's genitalia.

Children are not equipped with life experience and reasoning abilities to understand that the abuse or neglect is not their fault. They can suffer devastating developmental setbacks such as failure to thrive or developmental delays (learning problems), physical pain, and emotional anguish that lasts a lifetime.

What should I do if I suspect that a child has been maltreated?

If a child is in immediate danger or has been severely injured, call 911 or other emergency services.

If you are concerned that a child is being maltreated or neglected, call the police or local child protective services. You can make an anonymous report if you wish. Also, your local hospital may help connect you to local resources. Many hospitals have programs specifically related to child maltreatment.

What should I do if I am afraid someone close to me will harm my child?

If you believe your child is in immediate danger, call 911 and get your child to a safe location. If you are very concerned or afraid, arrange to stay in a safe place with your child. This may be the home of a close friend or family member, or a domestic violence shelter. A trusted health professional, a child abuse organization, or the police can guide you to find resources in your area.

If your partner or other caregiver has behaviors you are concerned about, schedule a quiet time to talk with that person alone. Help your partner learn about child development issues, such as by taking a parenting class together. Create an action plan of what to do next should your concerns become more serious.

Are health professionals required to report suspected maltreatment?

Health professionals and teachers, as well as those in other professions related to the care of children, are required by law to report suspected child maltreatment to the police or state child protection services. Law enforcement personnel will investigate and determine whether the situation requires prosecution. If convicted of a crime, an abuser may have to serve a jail sentence. The role of the juvenile court is to assure a child's safety and connect families to social services.

Although official definitions of maltreatment vary, health professionals in all 50 states are legally, morally, and professionally obligated to evaluate any signs of abuse or neglect.

How can I prevent child maltreatment?

• Take parenting classes. Many quality courses are available that can help you learn to effectively manage the demands and responsibilities of parenthood. All parents need to know how to react to difficult behavior effectively and nonviolently. These classes are especially valuable if you have a history of being abused. Also, become familiar with child development patterns so that your expectations of your child are realistic. Talk to your health professional or call your local hospital to find classes in your community.
• Learn stress-relief techniques. Taking care of yourself—by exercising, eating well, and getting rest—can help keep your stress level down. A variety of other strategies may also help, depending on your background and interests. For example, you may find self-help books or groups, religious organizations, or exercise classes such as yoga to be helpful. Anger management classes or professional counseling may sometimes also be needed.
• Teach your child the proper names for all the parts of his or her body and which parts are "private." Encourage your child to tell you if anything happens to a private part or if anyone wants him or her to do something with a private part.
• Listen to your child. Learn to recognize when something is bothering your child. Let him or her know it is safe to talk about anything with you.
• Screen all your child's potential caregivers and find out what they know about child health, development, and care. This may include getting permission for a police background check.
• Screen the television shows and movies your child watches and the computer games he or she plays. Limit and monitor access to Internet sites.
• Interact with and show concern for others. Simple measures, such as knowing the names of your neighbors and their children, can make a difference. Be an advocate for inexperienced and overwhelmed parents. Child abuse becomes less likely if parents or caregivers feel supported. Little things can help, such as offering to bring dinner for overtired parents when you see a need. On a larger scale, you may encourage parenting classes to be available in your community and support individuals or organizations that help parents at risk of abusing their children. Also, be familiar with the signs of abuse and neglect so you can recognize when there may be a problem.

Frequently Asked Questions

Abused or neglected children often show both physical and behavioral symptoms. Young children cannot talk about events. Older children may not talk about the problem because they fear or want to protect the offender, or they do not believe they will be taken seriously. Occasionally children report abuse to an adult they trust. These conversations should be taken seriously and acted upon.

Some symptoms are specific to certain forms of maltreatment. There are also general symptoms that can occur with all types.

General symptoms

Certain general symptoms that may suggest that a child is experiencing some type of maltreatment include:

• Developmental delays, which means a child does not reach developmental milestones as expected, such as starting to talk or socialize with others.
• Regression, which is losing skills once mastered and moving back to a earlier state of development.
• Failure to thrive, which is when a child's growth pattern is not in a healthy range. Both weight and height can be affected, but low weight for height and head circumference is the most common symptom. Most cases of failure to thrive are the result of problems with the immediate care of the child, the interaction between the child and the caregiver (usually the mother), or the social and emotional health of the caregiver.
• Unusual parent/child interaction. The parent may be uninterested in the child; children may be especially sensitive to the parents' moods and attempt to smooth over any potential conflict. Often, this appears as a type of role reversal, with the child closely monitoring and responding to the parent. Maltreated children may also fear their parents.
• Poor mental health, such as exhibiting low self-esteem, anxiety, depression, or suicidal tendencies.
• Sudden decline in academic performance.
• Problem or inappropriate behavior. In some cases, especially for a young child, unusual fussiness, fear, or lack of interest in activities may be noticed. Other behaviors may be disruptive. These are often learned; children often act out what they have seen or experienced, such as violence or sexual activity. Older children may act out by being promiscuous or running away.

Symptoms of physical abuse

Physical abuse often results in cuts, bruises, burns, broken bones, head injuries, and abdominal injuries. These types of injuries may indicate physical abuse when:

• They are unlikely to have been caused by an accident, especially for the child's developmental stage. Geometric patterns or mirror (symmetrical) injuries are suspicious, as are those located on areas of the body that usually are protected, such as the inside of the legs and arms, the back, the genitalia, and the buttocks.
• Explanations change or do not adequately account for how an injury occurred. The history of the injury does not match the actual type of injury, its location, or how long ago it occurred.
• Evidence shows that injuries have occurred previously.
• Medical care for the injury is delayed.

Symptoms of psychological abuse

A child who experiences psychological abuse has a parent or caregiver who uses tactics to hurt a child psychologically, such as by saying demeaning words or by failing to be supportive. The emotional pain caused by this type of abuse can devastate a child. An emotionally abused child may:

• Have little interest in what is going on around him or her and not be eager to try new activities.
• Have inappropriate responses to pain, other people, or changes in his or her environment.
• Avoid a parent or caregiver.
• Act overly fearful, angry, depressed, or anxious.
• Perform poorly in school.
• Inflict self-injury or be self-destructive.

Symptoms of sexual abuse

A child with symptoms of recent sexual abuse may be reluctant to go to the bathroom; show signs of discomfort or pain while sitting, urinating, or passing stools; have discharge from the vagina or penis; or bleed through his or her pants.

Certain behaviors may also indicate sexual abuse. These include:¹

• Age-inappropriate awareness and knowledge of sex or sexual behavior.
• Running away from home.
• Suicide attempts.
• Involvement with drugs or prostitution.

Symptoms of neglect

A child is neglected when he or she is not provided with appropriate care. A child's general appearance, home environment, and behavior patterns can show signs of neglect.

A child who is neglected may be:

• Significantly underweight or overweight.
• Developmentally delayed.
• Obviously unhealthy, such as being sick or tired most of the time.
• Dirty or have poor personal hygiene.
• Inadequately clothed.

In the United States during 2002, approximately 1,400 children died as a result of child maltreatment.² Survivors are vulnerable to long-term emotional damage. Typically, children are abused at an age when they are not equipped with life experience and reasoning abilities to understand that it is not their fault. They suffer developmental setbacks, physical pain, and emotional anguish. Maltreatment in children younger than 7 years of age may lead to permanent behavior and personality changes.

Children who are maltreated are at increased risk for abusing other children and siblings and, later in life, their own children or elderly parents. They are also at increased risk for becoming involved in criminal acts as they get older. As adults, they will likely suffer from physical and emotional problems.

Physical effects

Prolonged and repeated physical abuse can permanently damage the body.

• Certain types of abuse, such as shaken baby syndrome (also called intentional head injury), can result in life-threatening brain injury. Children who survive may have permanent developmental disabilities or learning disabilities.
• A sexually abused child can become infected with a sexually transmitted disease, such as HIV, which can be life-threatening.
• Long-term (chronic) health problems, such as irritable bowel syndrome and sexual dysfunction may occur. Other problems, such as osteoporosis, may develop as a result of being neglected as a child when proper nutrition was not provided.

Emotional effects

All children who have been abused or neglected or who witness domestic violence are at risk for developing mental health disorders, emotional problems, and poor social skills. These problems may occur alone or in combination. The effects of abuse or neglect are determined by its severity, how frequently or for how long it occurs, and the relationship of the child to the abuser.

Mental health disorders that may result from abuse and neglect include:

• Anxiety
• Depression.
• Borderline personality disorder. A person with this mental health condition has difficulty controlling his or her anger and impulses, has problems with unstable or intense relationships, has a low sense of self-worth, and feels frantic anxiety about being abandoned.
• Post-traumatic stress disorder.
• Suicide or suicidal thoughts.
• Dissociation. This is an unconscious attempt at self-protection against an overwhelming and traumatic experience. The mind separates itself from an event or the environment, such as blocking out the memory, so it can maintain some degree of order and sense.
• Eating disorders, such as severely limiting calories (anorexia) resulting in unhealthy weight loss.

Other emotional effects include:

• Low self-esteem, which is a person's core belief about himself or herself. Children cannot process or understand what has happened to them. They often unconsciously blame themselves and grow up with a poor self-image, which affects their relationships with others.
• Anger, hostility, defiance, antisocial tendencies, or criminal behavior.
• Negativity. A person with a history of abuse or neglect may have trouble adjusting to normal struggles.
• Substance abuse, such as using illegal drugs or drinking alcohol excessively.
• Emotional detachment. A person may have problems bonding, socializing, and developing friendships. This can result in isolation and a failure to learn and develop sympathy, empathy and other important emotion-based concepts.
• Impulsiveness. The person fails to think and consider the consequences before acting. Often, this results in reckless, risky, or antisocial activities, such as driving dangerously.
• Issues with sexuality. Abused or neglected children, especially those who are sexually abused, often have problems developing a healthy sexuality as they reach adolescence and adulthood. Some may be sexually promiscuous; others may be fearful and unwilling to risk any intimacy.

Living in poverty or near poverty is a major risk factor for child maltreatment. People who live in poverty often do not have the resources to properly care for their children. Caregivers may have high levels of stress that makes them less able to deal with daily challenges. Also, some children have extreme physical or psychological needs, which can make parenting very stressful. Unemployment, single and inexperienced parents, mental illness in a caregiver, poor housing, and substance abuse are all risk factors.

Risk factors for parents and caregivers

• A history of poor impulse control, violence, domestic violence, or abusing children.
• A history of substance abuse, which may include problems with alcohol.
• Unrealistic expectations of a child and lack of knowledge about childhood development.
• A high stress level that is not managed in healthy ways. Common sources of stress include being a single or teen parent or having several young children close in age.
• Lack of support and isolation. Parents who lack financial, emotional, and other types of support are more likely to abuse or neglect their children. A parent or caregiver who also lacks access to community social services may be left to deal alone with a variety of hardships.
• A history of having been abused. Caregivers who themselves were abused as children, have low self-esteem, are depressed, or have other mental health problems are more likely to react to stress with violence.
• A history of mental health problems, such as depression.

Risk factors for children

The risk of abuse and neglect increases when a child has a disability or other health issue, such as:

• Prematurity. Babies born early often add emotional and financial stress to a household by their need for longer and more expensive hospital care and general vulnerability that requires close monitoring once they are home. They may have persistent developmental problems.
• A physical disability, such as blindness or being confined to a wheelchair.
• Below-normal intelligence.
• Developmental delays.
• A difficult temperament.
• Behavioral problems, including attention deficit hyperactivity disorder (ADHD).

An insecure bond between parent and child is also a risk factor for abuse and neglect. The failure to establish a close bond may be the result of:

• Parents not wanting the child.
• Birth of twins or other multiples.
• Long hospitalization of the newborn and separation from parents because of premature birth or health problems.
• Challenges related to fostering or adopting a child.
• Mental health problems in a caregiver. For example, a parent who is severely depressed may unintentionally neglect his or her child.
• A child's being born with a major health problem or disability, such as blindness, deafness or autism. These types of problems can make it difficult for a parent to communicate or for the child to give and receive affection.

Call 911 or other emergency services immediately if you witness child abuse, believe a child is in immediate danger, or see that a child:

• Is not breathing. The 911 operator can guide you through cardiopulmonary resuscitation (CPR) until help arrives.
• Is having moderate to severe difficulty breathing.
• Is bleeding heavily.
• Has an altered level of consciousness.
• Is in shock.
• Exhibits symptoms of a head injury after being shaken.
• Has signs of severe dehydration.

Call your child's health professional, law enforcement, or children's services immediately if you:

• Suspect an injury was caused by maltreatment.
• Suspect that abuse or neglect is placing a child's health at risk.
• Suspect that a child witnesses domestic violence within the family.
• Have concerns that you, your spouse, or your significant other may lose control and hurt your child.

If the child is not in immediate danger, call your local child protective services, police, or a health professional if:

• A child tells you about being abused or neglected.
• You observe possible physical abuse injuries.
• You observe signs of sexual abuse.
• You observe signs of neglect.

ChildHelp, a nonprofit agency, provides telephone numbers and information about how to report suspected or observed child abuse or neglect. The national Child Abuse Hot Line number is 1-800-4-A-CHILD (1-800-422-4453). The U.S. Administration of Children and Families, under the Department of Health and Human Services, has established a Children's Bureau that supports the states in the delivery of child welfare services designed to protect children and strengthen families.³ For more information, see the Other Places to Get Help section of this topic.

In most states, child protection services are required by law to investigate potential child abuse or neglect within 24 hours.

A maltreated child who is taken to a health professional will first have a general physical examination. The child's medical history also is reviewed, and parents or caregivers are questioned about the child's condition. A child who is able to talk will be separated from the caregiver to be interviewed.

Health professionals have a professional duty and legal obligation to evaluate the possibility of abuse or neglect. Along with observing signs of physical abuse or neglect, a health professional may become suspicious when:

• The injury is uncommon or unlikely to be an accident, especially for the child's developmental stage.
• Explanations given by the parents or caregivers change or do not adequately account for the child's condition.
• There was no reported witness to the injury.
• Medical records document that similar injuries or patterns of neglect have occurred.
• Parents or caregivers delayed seeking medical help for the child without a credible or appropriate explanation.

Signs of sexual abuse may not be identified during a physical exam. Not all types of sexual abuse leave physical signs. Also, many types of sexual abuse injuries heal quickly. However, if a child is examined soon after the incident, a health professional is more likely to observe and record the symptoms and be able to take samples for lab analysis.

Common tests

Tests that are frequently used to help confirm or rule out suspected abuse or neglect include:

• Imaging tests such as X-ray, CT scan, or magnetic resonance imaging (MRI). These types of tests can help determine whether a child's injuries include any broken bones. Some tests may also show evidence of past injuries.
• Blood tests. Prothrombin time, partial thromboplastin time, and platelet count can help determine whether a bleeding disorder is present. This may help rule out abuse or neglect as a diagnosis. Other blood tests can be used to look for signs of organ damage.
• Urinalysis (UA), to check for blood in the urine. If the test is positive, this may be a sign of internal injuries.
• Specialized laboratory tests, to determine whether sexual abuse has occurred. For example, sample cultures of fluids found in or around the vagina may be taken and analyzed. If abuse has occurred within 72 hours of the exam, forensic samples of certain body tissues, such as skin or hair, also are taken.⁴
• Lumbar puncture, also called spinal tap, which may reveal blood from a brain injury.
• Eye examination by an ophthalmologist to determine if damage has occurred that indicates shaken baby syndrome, also called intentional head injury.

Other tests

Other exams and tests performed to help confirm child abuse or neglect vary depending on the specific medical problem suspected or observed. For example, psychological testing may be requested for some children. Victims of suspected sexual abuse may be tested for sexually transmitted diseases.

Other children in the care of a suspected abuser may also be examined and have X-rays if law enforcement or medical personnel investigating the case think it is necessary.

When a baby's death may be related to sudden infant death syndrome (SIDS), medical professionals and police officers will conduct a thorough investigation to rule out abuse or neglect. These people are trained to be sensitive to grieving parents. No one is at fault when a baby dies from SIDS. For more information, see the topic Sudden Infant Death Syndrome (SIDS).

Documentation

A child's injuries and related information are carefully recorded. This documentation provides a detailed account of the injuries for the child's permanent health record and usually includes photographs and drawings of the injuries. Measurements (weight, height, and head circumference) are also taken and recorded to help establish a child's baseline growth pattern. Recording these measurements on growth charts can help identify failure to thrive that sometimes is related to neglect. Neglect or other types of abuse may not be diagnosed immediately.

The first treatment priority for an abused or neglected child is to provide a safe environment to prevent further harm. Early treatment gives a child the best chance for physical and emotional recovery. This includes separating the child, as well as any other children in the household, from the suspected abusive parent or caregiver. Children who have higher-than-normal intelligence, specific talents, counseling, and support from a trusted adult are more likely to successfully manage the effects of their abuse.

A wide variety of therapies may be used for both children and parents. Specific treatment depends on the type of abuse, who inflicted it (perpetrator), and in what setting it occurred. Health and legal professionals work as a team to develop the most effective program using their training, experience, judgment, and creativity.⁵

Treatment for physical injuries

Treatment for an abused or neglected child depends on the nature of the abuse. If a child's injury or neglect has caused a life-threatening condition, such as shaken baby syndrome (also called intentional head injury), treatment will be given in a hospital setting. Less serious physical injuries, such as cigarette burns on the skin, will be treated on an outpatient basis with scheduled follow-up appointments.

Treatment for emotional injuries

Counseling is recommended for all children who are victims of abuse or neglect. For very young children, this treatment may involve play therapy. Counseling for children of all ages usually addresses:

• How they feel about themselves.
• Their past experiences.
• Fears and concerns they may have about the present and future.

Treatment for parents or caregivers

Parents or caregivers who have abused or neglected a child also need treatment. The type of treatment depends on the specific abuse that occurred. Some people need more education on effective parenting techniques. Others may need treatment for other serious problems, such as:

• Substance abuse.
• Depression or other mental health problems.
• Low self-esteem.
• Violent behavior.

Parents who have lost custody of their children may regain it. Whether they do so depends on the severity of the abuse or neglect and a professional evaluation of their rehabilitation progress. In severe cases, future contact between parent and child must be supervised. Sometimes all parental rights are lost.

You can help prevent child abuse and neglect by using techniques to help you manage the responsibilities and stress related to parenting and daily life. Regardless of whether you are a parent, you can help children by showing concern for their well-being, volunteering when you are able, and being a general advocate for them.

If you are a parent or caregiver of children:

• Learn and use effective parenting and discipline techniques and avoid the use of corporal punishment. Parenting classes are offered in most communities. Ask your health professional or call a local hospital for more information.
• Learn healthy techniques to resolve conflicts and manage stress. For more information, see the topic Stress Management.
• Ask for help when you need it. Call a family member or friend to give you a break if you feel overwhelmed. Investigate community resources that are available to help you with child care or other necessary services; call a health professional or local hospital for a place to start. Some communities have respite care facilities for children, which provide temporary child care during times when you need a break.
• Get treatment if you ever have been a victim of abuse. Also seek help if you have problems with depression, alcohol or substance abuse, or violent behavior.
• Increase your knowledge of children's developmental stages. The normal pattern of crying in a newborn is a common trigger for shaken baby syndrome (also called intentional head injury). For more information, see the Growth and Development topics.
• Remove firearms and other dangerous weapons from your home.

To help children in your community:

• Be aware of the children in your neighborhood. Learn their names and show basic concern for them, such as waving to them or asking about how they're doing at home and school.
• Relieve a friend, neighbor, or relative who is feeling overwhelmed with child care and other issues.
• Learn to recognize the signs of child abuse and neglect.
• Advocate for services to help at-risk families.
• Volunteer in child abuse programs.

When you suspect a child is, or is at risk of, being abused or neglected, it is important to take action. Most abused children are not able to help themselves.

Certain people, such as health professionals, social workers, and teachers, are required by law in all 50 states to report suspected child abuse and neglect, usually to the police or state child protection services. In some states, all citizens are mandated by law to report any suspicion of child abuse or neglect.³

In 2002, about 56% of the suspected child abuse reports were made by professionals in the line of duty. The remaining 44% of referrals were made by family members, neighbors, and other community members.²

Many people are unsure how to handle suspected abuse because they:

• Are not sure what acts are considered maltreatment.
• Fear they will cause the child more harm.
• Worry that they will falsely accuse a parent or caregiver.
• Fear that they will become a victim themselves of violence or harassment from the abuser.
• Are concerned they will be sued.

Keep in mind that by reporting suspected abuse or neglect, you may prevent a child from suffering serious injury, severe lifelong emotional problems, or even death. You also can make reports anonymously. If you give your name, it is kept confidential. A person who makes a report in good faith is immune from lawsuits.

Because in most states suspected abuse must be investigated within 24 hours, the risk of causing a child more harm by making a report is less than if you do not report your suspicions.

Investigators sometimes are not able to find enough evidence to support suspected abuse. In this case, parents or caregivers may be referred to social services to reduce the child's risk of abuse or neglect.

Organizations

• Choosing Child Care
• Depression
• Growth and Development, Ages 1 to 12 Months