pediatrics
Overview of Child Maltreatment
Classification of Child Maltreatment
Different forms of maltreatment often coexist, and overlap is considerable. The 4 main forms include Physical abuse Sexual abuse Emotional abuse Neglect In addition, intentionally feigning, falsifying, or exaggerating medical symptoms in a child that results in potentially harmful medical interventions is considered a form of abuse (child abuse in a medical setting). Physical abuse involves a caregiver inflicting physical harm or engaging in actions that create a high risk of harm. Assault by someone who is not a caregiver or in a position of responsibility to the child (eg, a shooter in a school mass shooting) is not specifically child abuse. Specific forms include shaking, dropping, striking, biting, and burning (eg, by scalding or touching with cigarettes). Infants and toddlers are the most vulnerable because the developmental stages that they may go through (eg, colic, inconsistent sleep patterns, temper tantrums, toilet training) may frustrate caregivers. This age group is also at increased risk because they cannot report their abuse. Abuse is the most common cause of serious head injury in infants. In toddlers, abdominal injury is also common. Children in these age groups are also at increased risk of brain and spine injuries because of the relative size of their head to their body and because they have weaker neck muscles. The risk of physical abuse declines in the early school years. Any action with a child that is done for the sexual gratification of an adult or significantly older (developmentally or chronologically) child constitutes sexual abuse ( see Pedophilic Disorder ). The guidelines that differentiate sexual abuse from play vary from state to state, but in general sexual contact between individuals with a > 4-year (chronologically, or in mental or physical development) age difference is considered to be inappropriate. Forms of sexual abuse include Intercourse, which is oral, anal, or vaginal penetration Molestation, which is genital contact without intercourse Forms that do not involve physical contact by the perpetrator, including exposure of the perpetrator's genitals, showing sexually explicit material to a child, sexting with or posting pictures of a child, and forcing a child to participate in a sex act with another person or to participate in the production of sexual material Sexual abuse does not include sexual play, in which children close in age and development view or touch each other’s genital area without force or coercion. Emotional abuse is inflicting emotional harm through the use of words or actions. Specific forms include Berating a child by yelling or screaming Spurning by belittling the child’s abilities and achievements Intimidating and terrorizing with threats Exploiting or corrupting by encouraging deviant or criminal behavior Emotional abuse can also occur when words or actions are omitted or withheld, in essence becoming emotional neglect (eg, ignoring or rejecting children or isolating them from interaction with other children or adults). Neglect is the failure to provide for or meet a child’s basic physical, emotional, educational, and medical needs. Neglect differs from abuse in that it usually occurs without intent to harm. Different types of neglect can be defined as Physical neglect includes failure to provide adequate food, clothing, shelter, supervision, and protection from potential harm. Emotional neglect is failure to provide affection or love or other kinds of emotional support. Educational neglect is failure to enroll a child in school, ensure attendance at school, or provide home schooling. Medical neglect is failure to ensure that a child receives appropriate care or needed treatment for injuries or physical or mental disorders. However, failure to provide preventive care (eg, vaccinations, routine dental examinations) is not usually considered neglect. Child abuse in a medical setting (previously called Munchausen syndrome by proxy, now called Factitious Disorder Imposed on Self in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) occurs when caregivers intentionally produce or falsify physical or psychologic symptoms or signs in a child. Caregivers may injure the child with drugs or other agents or add blood or bacterial contaminants to urine specimens to simulate disease. Victims of this type of child abuse receive unnecessary and harmful or potentially harmful evaluations, tests, and/or treatments, including procedures or surgeries. Severe corporal punishment (eg, whipping, burning, scalding) clearly constitutes physical abuse, but for lesser degrees of physical and emotional chastisement, the boundary between socially accepted behavior and abuse varies among different cultures. Likewise, practices that are accepted by some cultures constitute abuse in the US (eg, Female Genital Mutilation ). However, certain folk remedies (eg, coining, Members of certain religious groups have sometimes failed to obtain life-saving treatment (eg, for diabetic ketoacidosis or meningitis), resulting in a child's death. Such failure is typically considered neglect regardless of the parents’ or caregivers’ beliefs. Additionally, in the US, some caregivers refuse to have their children vaccinated, citing safety concerns ( see Vaccine Hesitancy ). It is not clear whether this refusal of vaccination is true medical neglect. However, in the face of illness, refusal of medically accepted treatment sometimes requires further investigation and legal intervention. 