Child Abuse (Non-accidental Trauma)

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Objectives

Upon finishing this module, the student will be able to:

  1. Understand the importance of a high index of suspicion for child abuse, particularly in children presenting with vague or nonspecific complaints.
  2. Describe the legal and ethical obligations of emergency medicine physicians regarding the reporting of suspected child abuse.
  3. Understand the role of imaging studies (e.g. skeletal survey, CT scan, MRI) in the evaluation of suspected child abuse.
  4. Describe the role of the emergency department in child abuse prevention efforts.

 

Contributors

Update Authors: Bradley S. Hernandez, MD; and Keith D. Henry, MD.

Original Author: Bradley S. Hernandez, MD.

Update Editor: Navdeep Sekhon, MD.

Original Editor: Veena Ramaiah, MD.

Last Updated: January 2025

Introduction

Child abuse, also known as non-accidental trauma or maltreatment, is unfortunately common in the United States, with an estimated 559,000 victims and 1,900 pediatric fatalities reported annually.1 Nearly one in eight children are abused before the age of 18 years old,2 and it is estimated that between 2-10% of children visiting the emergency department (ED) are victims of maltreatment.3 Child abuse is the third-leading cause of death in children between one and four years of age.4 Between 2008 and 2010, the incidence of abused children presenting to trauma centers across the U.S. rose sharply and remains high, with 3% of all trauma admissions under age 15 years due to non-accidental trauma.5

The U.S. Department of Health and Human Services defines the four main types of maltreatment as physical abuse, sexual abuse, neglect, and emotional abuse. The largest percentage of maltreated children are victims of neglect (74%), and a smaller percentage of children are victims of physical abuse (17%) or sexual abuse (11%).1

Child abuse affects all races, religions, and classes, but children in socioeconomically disadvantaged families are at greater risk. Compared with white and Hispanic children, African-American and Native American children have a significantly higher rate of maltreatment, and African-American children have a mortality rate that is 3.5 times greater than other ethnicities. Females comprise a higher percentage of child abuse and neglect victims, but there is a higher rate of fatality in male children.1 Additionally, insurance status is a determining factor, with both uninsured status and Medicaid-associated with increased mortality when compared to patients with private insurance.6

It is well known that the younger the child, the more likely they are to suffer from maltreatment. While the finger is often pointed at non-parent adults, 89% of abuse involves the child’s parents, and mothers are involved more often than fathers due to increased exposure to the children. Non-parents only represent 15% of cases of child abuse (there is some overlap due to involvement of both parent and non-parents). Despite the female predominance of perpetrators of child abuse cases overall, the death of a child is more likely to be caused by a male.1 Young children less than one year of age, who are the most vulnerable to trauma, have the highest fatality rate, so while they comprise only 15% of total cases, they suffer 45% of all child abuse fatalities. Two-thirds of all fatalities are under the age of three.1 Any characteristic that that makes a child more difficult to care for predisposes them to maltreatment. Examples include children with:

  • Chronic illnesses or special health care needs.
  • Emotional or behavioral disabilities.
  • Physical aggression or antisocial traits.
  • Physical or developmental disabilities.

Premature delivery may also increase a child’s vulnerability to abuse.8-9 Rates of child maltreatment by unemployed parents are two-three times higher. Child abuse is also more common if the parents suffer from substance abuse or mental illness.7 Factors that decrease a parent’s ability to cope with stress increase the potential for maltreatment, including low self-esteem, poor impulse control, a young age, low educational achievement, poor social support, and mental illness. Parents who were victims of child maltreatment themselves, or who currently have an abusive partner, are more likely to be abusive parents.8

Part of the difficulty to diagnose child abuse is that the definition of exactly what constitutes child abuse is highly variable. It can range from severe physical or sexual abuse to subtle neglect or emotional abuse. Neglect occurs when a child's basic needs are not adequately met. These basic needs include food, clothing, stable housing, supervision, protection, health care, education, and nurturing.8 Munchausen syndrome by proxy is the abuse of a child in a medical setting. In 2007, the American Academy of Pediatrics (AAP) changed the name to "fabricated illness in a child" in order to maintain the focus on the child victim rather than the behaviors of the caregiver.10

Another difficulty in diagnosis is because the line between punishment and abuse is very subjective to different parents, communities, legal systems, legislatures and medical providers. The U.S. Government enacted the Child Abuse Prevention and Treatment Act in 1974, which provided an initial definition of child abuse. The 2010 Child Abuse Prevention and Treatment Act revised the definition to “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.”11

The World Health Organization (WHO) defines child abuse as "all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power."12 It is this variability in definition that contributes to the difficulty in identification, prevention, correction, and legal action.

 

Case Study
A four-month-old male presents to the ED with a three-day history of fussiness. Per the mother, the patient has been more fussy than usual and has not been as interested in feeding. The patient is making a normal amount of wet diapers and stools. The patient's vital signs are normal for age. On physical examination, you note som rectangle-shaped bruises on the upper back and buttocks in various stages of healing.
Prevention

As front-line providers, it is the role of the emergency physician to maintain a high index of suspicion with every pediatric patient encountered because the clues to diagnose maltreatment may be very subtle. It is equally important to maintain an open mind about possible injury patterns. Above all else, the physician should have a non-threatening and non-accusatory approach. Unfortunately, it often goes unrecognized until severe injury or death occurs. A study of 44 children who died of child abuse showed that 19% of them were evaluated by a physician within a month of their death, and 71% of those evaluations were in an ED. The ED complaints at these visits ranged from fussiness to vomiting and poor feeding.13 A 2010 study showed that nearly one-fifth of abuse-related fractures had at least one previous physician visit during which the abuse was missed.14

Regrettably, the number of reported cases is estimated to be only 5-20% of the actual cases of abuse.15 There is abundant evidence that physicians often miss opportunities for early identification and intervention.8 Unfortunately, despite the importance of epidemiologic information, obtaining precise estimates of the prevalence and incidence of childhood maltreatment is difficult. This is because most events occur in private circumstances and rarely are observed by others; so only perpetrators and children have knowledge of the events. Child victims are often preverbal, too frightened, or embarrassed to reveal what is happening, or they don’t understand that what is happening to them is wrong.8,16

Multiple triage screening tools have been developed and proven somewhat effective in the recognition of at-risk children. These tools can then alert providers that a more thorough history and physical exam may be needed. The American College of Surgeons requires all trauma centers to have a triage screening process for child abuse.17 Shahi et al. developed a routine two-question ED triage screening tool that successfully identified children at risk of physical abuse without impacting ED length of stay or resource utilization.18 Another screening system, the Red Flag Scorecard, may serve as an effective checklist tool to raise suspicion for child physical abuse in emergency centers.19 The key to any screening tool is to identify the sentinel injury and prevent any additional risk for the child. There are recent consensus recommendations for the radiological screening of contact children/siblings in the context of suspected child physical abuse, recognizing their high risk and the need to advocate for close contacts of impacted children.22

History and Physical Exam

The history for a child with an injury with suspected maltreatment should include a thorough past medical history including prior injuries, trauma, or illnesses, as well as any underlying medical conditions. An accurate, detailed description of the circumstances surrounding a suspicious injury should also be obtained from everyone involved with the child’s care. This includes the child, parents, caregivers, and witnesses. If possible, the child and caregivers should be interviewed separately. Historical evidence of maltreatment include:

  • History is inconsistent with the type or severity of injury.
  • A changing history when told by the same or different caregivers.
  • History is inconsistent with developmental stage.
  • An unexplained delay in seeking care (in a recent retrospective study, a delay to seeking care was the most common historical finding19).

In cases of non-accidental trauma, the focus should not only be on the injury, but also on the child as a whole. Look at their general appearance to determine if they appear to be well cared for and developing normally.4 Observe their interactions with their caregivers. The child’s age and development should be taken into account when evaluating any child with any musculoskeletal or skin injury other than superficial abrasions.20 The child should be completely undressed and the skin thoroughly examined. All skin findings should be documented – traumatic and non-traumatic. This includes congenital findings such as birthmarks. Bruising is the most common presenting feature of physical abuse in children. Young children often have bruises on their forehead and extremities from routine behavior. More concerning are bruises away from bony prominences, such as those which involve the torso, neck, ears, or buttocks. The oral cavity should be examined specifically looking for frenulum injury in infants and dental trauma. Bruises or burns that have a patterned or sharp demarcation are highly suspicious for non-accidental trauma as a cause.

Radiographic Imaging

Initial radiographic imaging should be based on clinical findings, however this is age-dependent. Young children can have occult fractures and the skeletal survey remains a mainstay of evaluation. It is critically important to look for evidence of old, healed fractures when reviewing pediatric radiographs. It has been estimated on post-mortem examinations that half of infants who die from suspected abuse had signs of prior abuse such as fractures. If an injury is suspicious for abuse, current recommendations by the AAP are for a complete skeletal survey to be performed in the ED if the child is less than 24 months old. The usefulness of skeletal survey in children older than five years is low, and it is of variable yield in children two-five years old. Results of a 2011 study showed a yield of 10.8% positive results out of 703 skeletal surveys. The highest rates of positive skeletal surveys were found in children less than six months of age, patients with ALTE or seizure, and children with suspected abusive head injury.4

The skeletal surveys protocol includes 21 images which should be separate, high-quality radiographs of every bone including the skull. A "babygram" with multiple areas on the same image is not acceptable and lowers the sensitivity of the survey.7

Head CT should only be done in children less than one year of age with suspected abuse and in those with abnormal neurologic findings. Dilated ophthalmologic examination to diagnose retinal hemorrhages is only recommended when abusive head trauma is suspected. In children with other signs of physical abuse and children without abnormalities on CNS imaging, a dedicated retinal examination is usually not necessary.21

Lab Testing

Lab testing is guided by the age of the child, the severity of injury, and the purpose of the testing. For infants in whom screening lab testing may elucidate occult injury, bloodwork is recommended. This includes CBC, coagulation studies, LFT’s, lipase, and non-cath urinalysis. In older children, lab testing is guided by clinical presentation. This could include screening trauma labs for more severe injury or injury specific labs. For any child with extensive musculoskeletal injury, consider rhabdomyolysis and consider performing urinalysis, serum CK, BUN, and creatinine. Urinalysis, hepatic transaminases and lipase have been used to detect occult intra-abdominal injury primarily in infants but are less useful in older children.4,25

Injuries
Bruises

Bruising is the most common presenting feature of physical abuse in children.33 While no bruise is diagnostic for abuse, multicolored bruises in different stages of healing are certainly suspicious. The pattern and location of bruising on the body also can be helpful. Unintentional bruises in mobile children typically occur over bony prominences on the anterior aspect of the body, such as the knees, shins, or forehead. Bruises suggestive of abuse include those that are on the soft tissues, buttocks, neck, or trunk. Patterned bruises suggest that they could have been inflicted by an object. When documenting bruises, color, size, shape, and location are important. Bruises should generally prompt radiographic imaging studies because they may be the only visible clue to a fracture or old healing injury. Bruising in infants, especially those who are not mobile, is highly concerning for inflicted injury. The expression “those who don’t cruise rarely bruise” is important to remember in evaluations.27 Even a single bruise on an infant should heighten concern for abuse.

Fractures

After bruises, fractures are the second most common injury caused by child abuse.26 Children's bones have structural properties that allow them to withstand greater force. In any aged child, unexplained fractures, fractures with improbable mechanism, and the presence of multiple fractures in different stages of healing raise suspicion for non-accidental trauma. Up to 80% of fractures caused by child abuse occur in children younger than 18 months of age.28 The ED provider should consider whether abuse is a possibility in every child with a fracture, particularly in children less than three years old. Up to 20% of fractures in children less than three which were caused by abuse are incorrectly attributed to other causes.34

While some fracture patterns are highly suggestive of physical abuse, no pattern can prove or disprove child abuse.34 The AAP has published a clinical report that categorizes fractures in children as high, moderate, or low "specificity for abuse." Fractures, especially in infants, which have high specificity for abuse are sternal fractures, scapula fractures, spinous process fractures, and rib fractures (especially posteriormedial ribs). Fractures with low specificity for abuse include long bone fractures, clavicle fractures, and linear skull fractures.33 It is a common misconception that spiral fractures are pathognomonic for abuse, but that is no longer felt to be true.29

Head Trauma

Abusive head trauma is the leading cause of morbidity and mortality from physical abuse. Infants less than one year old are specifically at risk. Any child with physical evidence of head trauma should be thoroughly evaluated and clinical decision rules should be used to determine whether imaging should be performed. The Pediatric Emergency Care Applied Research Network (PECARN) has established clinical decision rules which currently are the most commonly used in clinical practice and recently updated.30 Subdural hematomas are the most common type of ICH associated with abuse, whereas epidural hematomas are rarely associated with non-accidental trauma. Other common head CT abnormalities include cerebral edema, hypoxic-ischemic injury, and retinal hemorrhages. Symptoms can often be as vague as poor feeding, excessive crying, lethargy, or seizures. Crying is a common trigger for abusive head trauma. Infant crying generally peaks between two-four months, and the incidence of abusive head trauma is highest during this period.7-8

Shaken baby syndrome, which is a severe consequence of child maltreatment, can affect children aged five and below and continues to be a major contributor to infant and child mortality rates.6 In 2009, the AAP issued a policy statement which endorsed the term "abusive head trauma" to describe injury in infants and children that resulted from violent shaking, blunt impact, or a combination of both. This term has taken the place of "shaken baby syndrome" because the provider typically does not know the mechanism by which a child was injured.23

Reporting

Each year in the U.S., Child Protective Service (CPS) agencies receive more than three million reports of suspected child maltreatment and investigate more than two million of the reports. More than 500,000 of these cases are substantiated as abused children.8 Federal law requires states to have reporting laws for health care providers regarding child maltreatment. Physicians are mandated reporters in 48 states, and the remaining two states mandate that all persons report child abuse. Unlike a crime, the threshold for reporting maltreatment does not require incontrovertible evidence. The statue reads that a report should be made when a healthcare professional “reasonably suspects” or has “reason to believe” that a child has been abused or neglected.1 All state laws provide some type of immunity for good-faith reporting.35

Reporting suspected child abuse generally involves notifying a local CPS office or law enforcement agency.7 Every state is required to establish a response system. The Health Insurance Portability and Accountability Act (HIPAA) is often perceived to be a barrier to abuse reporting, but HIPAA specifically permits disclosures to “a public health authority or other appropriate government authority authorized by law to receive reports of child abuse or neglect.” Most states consider mandated reporting of child maltreatment exempt from the physician-patient privilege of confidentiality. Reporting child maltreatment is the most important preventative measure the emergency provider can do, even in cases where maltreatment is only suspected. The mortality rate from each recurrent abusive event is 25%.1 Abused children are at high risk for fatal injuries and many children who die from abuse were victims of previous episodes of maltreatment that were either not discovered or not reported.

Documentation

Meticulous documentation of the details of the history and physical exam findings are critical both for the child’s future care and legal purposes. Quotes should be used whenever possible, and documentation should be double checked for accuracy. Photography is the best way of documenting injuries and is best performed by a law enforcement agency with approved forensic cameras.7 It should be done with informed consent of the parents whenever possible. It is important to document any shapes and patterns of injuries such as hands, belt buckles, or bite marks. But if there are injuries without clear patterns the ED provider should not pass judgment when documenting.

Outcomes

The lifelong consequence of child abuse is profound. Maltreated children exhibit high rates of physical, developmental, and mental health deficits during childhood. Victims of maltreatment are more likely to develop behavioral problems such as conduct disorders, aggressive behaviors, poor academic performance, and decreased cognitive functioning.8 They are also five times more likely to attempt suicide.31 There is also an association between maltreatment and poor adult health, which is cumulative. The greater amount of traumatic childhood experiences such as maltreatment, family dysfunction, and social isolation a child experiences, the higher the risk for poor health in adulthood.8 There is growing evidence that even harsh discipline and punishment of children has a deleterious effect throughout a child’s life.24

Conclusion

Unfortunately, hospitalization rates for physical abuse have not decreased; in fact there has been a small increase in recent years.8 It is important to remember that up to 10% of pediatric injuries seen in the ED are caused by abuse.32 ED providers need to remain vigilant to the possibility of child maltreatment, remember their professional mandates, and advocate on behalf of abused children. The importance of prevention through intervention services can result in a large public health impact. The role of the emergency provider in child abuse is to:

  1.  Identify injuries suspicious for abuse.
  2. Facilitate a thorough investigation.
  3. Treat medical needs.
  4. Assist in determining a safe disposition for the patient.
  5. Provide an unbiased medical consultation to law enforcement.
  6. Provide ethical testimony if called to court.

Emergency providers are in a prime position to identify abuse early, before significant morbidity or mortality occurs. There is an increased risk of mortality with each recurrent abusive event. Maintaining a high clinical suspicion for high-risk cases of abuse remains the most important skill one can have in helping to curb what is a worldwide social problem.8

Pearls and Pitfalls
  • Have a high index of suspicion as children suffering from mistreatment are often not picked up on their initial ED evaluation.
  • Physicians have a duty to report suspected child maltreatment. Laws protect "good-faith" reporting.
Case Study Resolution
A skeletal survey is ordered, which shows multiple rib fractures in various stages of healing. Concerned for child maltreatment, you contact Child Protective Services (CPS), who comes to evaluate the patient and make a safe plan for the patient.
References
  1. Child Maltreatment 2022. Administration for Children and Families. Administration on Children, Youth, and Families. Children's Bureau. U.S. Department of Health & Human Servcies.
  2. Gwirtzman-Lane W. Prevention of Child Maltreatment. Pediatr Clin North America. 2014.
  3. Leetch AN, Woolridge D. Emergency Department Evaluation of Child Abuse. Emerg Clin N Am. 2013.
  4. Gilbert R, Widom CS, et al. Burden and Consequences of Child Maltreatment in High-Income Countries. Lancet. 2009.
  5. Rosenfeld EH, Johnson B, et al. Understanding Non-Accidental Trauma in the United States: A National Trauma Databank Study. J Pediatr Surg. 2020.
  6. Alter N, Hayashi J, et al. A Narrative Review Investigating Practices and Disparities in Child Abuse Among United States Pediatric Trauma Patients and Associated Outcomes. J Surg Res. 2024 Jul.
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  8. Definitions of Child Abuse and Neglect in Federal Law. Child Welfare Information Gateway. 2016.
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  10.  Deans KJ, Thackeray J, et al. Mortality Increases with Recurrent Episodes of Non-Accidental Trauma in Children. J Trauma Acute Care Surg. 2013.
  11. Duffy SO, Squires J, et al. Use of Skeletal Surveys to Evaluate for Physical Abuse: Analysis of 703 Consecutive Skeletal Surveys. Pediatrics. 2011 Jan.
  12. Fan T, et al. Putting Prevention into Practice. U.S. Preventive Services Task Force Program. Agency for Healthcare Research and Quality. 2014.
  13. National Data Archive on Child Abuse and Neglect (NDACAN). Bronfenbrenner Center for Translational Research. Cornell University College of Human Ecology. 2016.
  14. Petska H, et al. Sentinel Injuries - Subtle Findings of Physical Abuse. Pediatr Clin North America. 2014.
  15. Kempe CH, Helfer RE. The Battered Child, 3rd ed. University of Chicago Press. 1983.
  16. Maguire S, Hunter B, et al. Diagnosing Abuse: A Systematic Review of Torn Frenum and Other Intra-Oral Injuries. Arch Dis Child. 2007.
  17. ACS Trauma Quality Programs: Best Practice Guidelines for Trauma Center Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence. American College of Surgeons Committee on Trauma. 2019 Nov.
  18. Shahi N, Meier M, et al. Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency. Pediatr Emer Care. 2024.
  19. Naik-Mathuria B, Johnson H, et al. Journal of Pediatric Surgery. 2023.
  20. Rosen P, Barkin R. Emergency Medicine Concepts and Clinical Practice, 4th ed. Mosby. 1998.
  21. Greiner MV, Berger RP, et al. Examining Siblings to Recognize Abuse (ExSTRA) Investigators: Dedicated Retinal Examination in Children Evaluated for Physical Abuse Without Radiographically Identified Traumatic Brain Injury. J Pediatr. 2013 Aug.
  22. Mankad K, et al. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse. JAMA Pediatr. 2023 Mar 6.
  23. Hung KL. Pediatric Abusive Head Trauma. Biomed J. 2020 Jun.
  24. Scribano PV, Makoroff KL, et al. Association of Perpetrator Relationship to Abusive Head Trauma Clinical Outcomes. Child Abuse Negl. 2013 Oct.
  25. Singh NV, Lichtsinn K, et al. Urinalysis in Suspected Child Abuse Evaluation in the Emergency Department. Pediatr Emerg Care. 2024 Jul 1.
  26. Thornton MD, Della-Giustina K. Emergency Department Evaluation and Treatment of Pediatric Orthopedic Injuries. Emerg Med Clin North America. 2015.
  27. Sugar NF, et al. Bruises in Infants and Toddlers: Those who Don't Cruise Rarely Bruise. Arch of Pediatric and Adolescent Medicine. 1999.
  28. Schilling S, Christian CW. Child Physical Abuse and Neglect. Child Adolesc Psychiatric Clin N Am. 2014.
  29. Schwartz KA. Child Maltreatment: A Review of Key Literature in 2013. Curr Opin Pediatr. 2014.
  30. Holmes JF, et al. PECARN Prediction Rules for CT Imaging of Children Presenting to the Emergency Department with Blunt Abdominal or Minor Head Trauma: A Multicentre Prospective Validation Study. The Lancet Child and Adolescent Health.
  31.  Stirling J. Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. Pediatrics. 2007.
  32. Narang, et al. Legal Issues in Child Maltreatment. Pediatr Clin North America. 2014.
  33. Flaherty EG, et al. Evaluating Children with Fractures for Child Physical Abuse. Pediatrics. 2014.
  34. Ravichandiran N, Schuh S, et al. Delayed Identification of Pediatric Abuse-Related Fractures. Pediatrics. 2010.
  35. Christian CW, Committee on Child Abuse and Neglect - American Academy of Pediatrics. The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015 Sep.