Few social problems have as profound an impact on the well-being of children as child abuse and neglect. Each year in the United States, 3 million reports of suspected maltreatment are made to child welfare agencies. Approximately 1 million of these reports are substantiated after investigation by Child Protective Services (CPS). These reports represent only a small portion of the children who suffer from maltreatment. Parental surveys indicate that several million adults admit to physical violence against their children each year, and many more adults report abusive experiences as children. Federal and state laws define child abuse and neglect. Each state determines the process of investigating abuse, protecting children, and holding perpetrators accountable for their actions or inactions. Adverse childhood events, such as child abuse and neglect, increase the risk of the individual’s developing behaviors in adolescence and adulthood that predict adult morbidity and early mortality. The ability to recognize child maltreatment and effectively advocate for the protection and safety of a child is a great challenge in pediatric practice that can have a profound influence on the health and future well-being of a child.
Child abuse is parental behavior destructive to the normal physical or emotional development of a child. Because personal definitions of abuse vary according to religious and cultural beliefs, individual experiences, and family upbringing, various physicians have different thresholds for reporting suspected abuse to CPS. In every state, physicians are mandated by law to identify and report all cases of suspected child abuse and neglect. It is the responsibility of CPS to investigate reports of suspected abuse to ensure the ongoing safety of the child. State laws also define intentional or reckless acts that cause harm to a child as crimes. Law enforcement investigates crimes such as sexual abuse and serious physical abuse or neglect for possible criminal charges against a perpetrator.
Child abuse and neglect are often considered in broad categories that include physical abuse, sexual abuse, emotional abuse, and neglect. Neglect is the most common, accounting for approximately half of the reports made to child welfare agencies. Child neglect is defined by omissions that prevent a child’s basic needs from being met. These needs include adequate food, clothing, supervision, housing, health care, education, and nurturance. Child abuse and neglect result from a complex interaction of individual, family, and societal risk factors. Although some risk factors, such as parental substance abuse, maternal depression, and domestic violence, are strong risk factors for maltreatment, they are better considered as broadly defined markers to alert a physician to a potential risk, rather than determinants of specific abuse and neglect.
The ability to identify victims of child abuse varies by the ageof the patient and the type of maltreatment sustained. Childrenwho are victims of sexual abuse are often brought for medical care after the child makes a disclosure, and the diagnosis isstraightforward. Physically abused infants may be brought for medical evaluation of irritability or lethargy, without a disclosure of trauma. If the infant’s injuries are not severe or visible, the diagnosis may be missed. Approximately one third of infantswith abusive head trauma initially are misdiagnosed by unsuspecting physicians, only to be identified after sustaining furtherinjury. Although physicians are inherently trusting of parents, aconstant awareness of the possibility of abuse is needed.
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