Diagnosing Child Abuse at Retail Clinics

One in 4 children in the United States is a victim of physical abuse, sexual abuse, psychological abuse, or neglect at some point in his or her life. A frightening reality, child maltreatment claims more than 1500 lives every year.¹More often than not, perpetrators will deny their mistreatment and the child victims are afraid and confused.²Nurse practitioners and physician assistants must acknowledge the magnitude of this problem and prepare themselves to recognize, assess, diagnose, and respond to patients presenting with signs of maltreatment.

Types of Child Maltreatment

Physical Abuse

Physical abuse is defined as any act that leads to the nonaccidental physical injury of a child.²It may include punching, beating, kicking, biting, shaking, throwing, stabbing, choking, poisoning, or burning the child.³Often, the abuse results from unreasonable corporal punishment that involves hitting the child with a hand, stick, strap, or other object.²Subsequent injuries are regarded as physical abuse regardless of whether the caregiver intended to hurt the child.³

Sexual Abuse

Sexual abuse includes any sexual act that involves a child, such as fondling, exhibitionism, fellatio, cunnilingus, and penetration of the vagina or anus with sexual organs or objects.³The perpetrator and the child may be the same or different genders. Sexual abuse also encompasses exploitation of the child through forcing, tricking, enticing, or threatening the child to participate in sexual acts for the gratification of others, such as trafficking, prostitution, and pornography.²

Psychological Abuse

Psychological abuse, often called emotional abuse, refers to nonaccidental verbal or symbolic acts by a caregiver that have a reasonable potential of causing harm to a child.²It commonly occurs when a caregiver conveys that the child is worthless, unwanted, flawed, or endangered.³Psychological abuse includes the following: (1) verbal assaults such as belittling, screaming, and blaming; (2) exposing the child to violence; (3) pressuring with excessive expectations; or (4) telling the child to participate in criminal or antisocial behaviors.²

Neglect

Neglect is defined as any malicious act or omission by a child’s caregiver that denies that child their basic needs and has the reasonable potential to result in physical or psychological damage.²Child neglect includes abandonment, lack of age-appropriate supervision, failure to tend to the child’s emotional needs, and failure to provide necessary education, medical care, food, water, shelter, and clothing. Medical neglect refers specifically to a caregiver’s withholding or delay in providing adequate medical care.³

Scope of the Problem

Child maltreatment is a major public health concern. In fact, child protective services estimated that 686,000 children were victims of maltreatment in 2012 alone. Among these children, 78% experienced neglect, 18% experienced physical abuse, 9% experienced sexual abuse, and 11% experienced other types of maltreatment, including psychological abuse.¹Maltreatment occurs most commonly in infancy and early childhood, with the latest research demonstrating that this abuse causes long-term damage to the neuroendocrine system. Childhood abuse impairs brain development and leads to cell loss, myelination delays in the hippocampus and prefrontal cortex, and chronic inflammation.³

The National Longitudinal Study on Adolescent Health investigated the consequences of childhood maltreatment in a group of 12,118 American teenagers. Among the maltreated adolescents in this study, 28.4% reported physical abuse, 11.8% reported neglect, and 4.5% reported sexual abuse. These teenagers also indicated higher rates of depression, alcohol use, binge drinking, marijuana use, obesity, inhalant use, and aggressive behaviors.³

Related Federal and State Laws

The Child Abuse Prevention and Treatment Act was passed in 1974 and amended most recently in 2003. At the federal level, child abuse and neglect are recognized as any act (abuse) or failure to act (neglect) on the part of the caregiver that results in death, serious physical injury, emotional harm, sexual abuse, or sexual exploitation of a child.³

At the state level, each jurisdiction has its own definitions and rules regarding child maltreatment. All states, however, require suspected abuse and neglect to be reported even without definitive evidence. Nurse practitioners and physician assistants can locate information about their state’s laws at childwelfare.gov.⁴

Etiology

Child maltreatment occurs across all socioeconomic classes; however, it is strongly correlated with poverty, psychosocial stress, and caregiver substance abuse and mental illness. Physical abuse specifically is associated with caregivers who are uneducated, unemployed, rely on welfare, and have many children. Children with intellectual disabilities and physical handicaps are more likely to be abused than are other children. Incestuous behaviors are associated with alcohol abuse, overcrowding, and rural isolation.³

Assessment

Clinical Features

Maltreated children present with a variety of emotional, behavioral, and somatic symptoms. They may appear fearful, docile, and guarded or they may be disruptive and aggressive. A child might be wary of physical contact or show no expectations of being comforted by his or her caregiver.

Physically abused children tend to present with evidence of repeated, suspicious injuries.³They may appear with bruises, lacerations, burns, bites, and other skin injuries.⁴Neglect may also manifest as extensive dental caries, severe diaper dermatitis, and neglected wound care. Bald spots on the scalp can indicate severe nutritional deficits.³

Sexually abused children may present with periods of amnesia and trancelike states.²They may have a history of masturbating with objects, imitating intercourse, showing their genitals to other children, or inserting objects into their vagina or anus.³Their somatic complaints tend to include enuresis, encopresis, anal and vaginal itching, anorexia, headache, and stomachache.²

Abusive caregivers often feel guilty and delay seeking treatment for their children’s injuries.²They may provide an unbelievable history that appears inconsistent with the types of injuries present.⁴Sometimes, caregivers blame other siblings or state that the child injured himself or herself.

The following caregiver explanations should raise concern⁴:

• The caregiver provides no explanation.
• An important detail changes significantly from one telling of the story to the next.
• The explanation is implausible given the severity of the injury.
• Different witnesses offer substantially different explanations.

History

If child maltreatment is suspected, the clinician should gather as much information as possible while appearing calm and nonaccusatory. The history should include⁴:

• Past trauma, hospitalization, congenital conditions, and chronic illnesses
• Family history of bleeding, bone, and metabolic disorders
• Pregnancy history, such as wanted/ unwanted pregnancies, prenatal care, and postpartum depression
• Familiar patterns of discipline
• Child temperament
• History of past abuse to child, siblings, or parents
• Child developmental history, such as language, gross motor, fine motor, and psychological milestones
• Presence of substance abuse in the caregiver or others living in the home
• Social and financial stressors and resources
• Violent interactions among other family members

Physical Examination and Diagnostic Testing

In addition to a traditional general exam, practitioners should focus on skin, cranial, abdominal, and skeletal injuries (Table⁴). Clinicians should perform a thorough physical exam and obtain diagnostic imaging and blood work when necessary.

TABLE: COMPONENTS OF EXAM OF CHILD WITH SUSPECTED MALTREATMENT⁴

Area of Focus

Possible Findings

Suspected Form of Abuse

Diagnostic Tests

Rule Out

Notes

Skin

Bruises, grab marks, bite marks, lacerations, burns, shoe or knuckle imprints

Shaking, grabbing, biting, kicking, burning

Blood tests for hematologic disorders, including complete blood count, platelet count, prothrombin time, international normalized ratio, and partial thromboplastin time

Accidental injury

Inflicted injuries tend to occur on surfaces away from bony prominences; bite marks should be photographed when possible; accidental burns usually have splash marks.

Head

Intracranial and extracranial injury, subdural and subarachnoid hematoma, retinal hemorrhage

Shaking, throwing, hitting

Magnetic resonance imaging of the head and neck, CT scan of the head

Glutaric aciduria type 1 and hemorrhagic

disease of the newborn

Retinal hemorrhages occur in

85% of children who are abused through shaking.

Torso

Shallow breathing, hemopericardium, cardiac contusions, chylothorax, abdominal muscle rigidity, no bowel sounds, hollow viscus injury, liver injury, pancreatic injury

Rib fractures, forceful squeezing, punching in the chest or abdomen

Liver enzymes, pancreatic enzymes, urinalysis, cardiac enzymes, CT scan of the abdomen

Accidental falling or tripping

Inflicted

abdominal injuries occur in younger children, and their caregivers are more likely to delay seeking treatment.

Skeletal

Fractures to the legs, arms, feet, hands, ribs, and head; metaphyseal and spiral/oblique fractures

Grabbing, pulling, twisting

Skeletal survey of arms, legs, skull, spine, and pelvis; radionuclide bone scan

Osteogenesis imperfecta, bone-mineralization disorders such as rickets

Abuse is sometimes suspected in children with osteogenesis imperfecta prior to diagnosis.

DSM-5 Diagnostic Criteria

The American Psychiatric Association lists physical abuse, sexual abuse, neglect, and psychological abuse in itsDiagnostic and Statistical Manual of Mental Disorders, 5th edition, under the “Other Conditions That May Be a Focus of Clinical Attention” section.³Each of these 4 diagnoses can be coded as confirmed or suspected and as initial encounter or subsequent encounter.

Management

Once a diagnosis of maltreatment has been made based on a child’s history and physical exam, clinicians are mandated to report their findings to the appropriate investigative agency. The most pressing intervention is to ensure the child’s future safety.³Any acute injuries should be treated, and the child should be referred to a mental health specialist. Nurse practitioners and physician assistants must document their findings and provide their expertise to legal personnel when deemed appropriate.

Melissa DeCapuais a board-certified psychiatric nurse practitioner. She currently works as a consultant for small health care technology companies, and she recently won the Seattle Health Innovator award. Dr. DeCapua is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Dr. DeCapua, visit her website at melissadecapua.com and follow her on Twitter @melissadecapua.

References

1. Promoting safe, stable and nurturing relationships: A strategic direction for child maltreatment prevention. Centers for Disease Control and Prevention website. cdc.gov/ViolencePrevention/pdf/CM_Strategic_Direction--OnePager-a.pdf. Accessed April 16, 2016.
2. Sadock BJ, Sadock, VA, Ruiz, P.Synopsis of Psychiatry. 11th ed. Philadelphia, PA: Wolter’s Kluwer; 2015.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.5th ed. Arlington, VA: American Psychiatric Association; 2013.
4. Kellogg ND. Evaluation of suspected child physical abuse.Pediatrics. 2007;119(6):1232-1241. doi: 10.1542/peds.2007-0883.