Overview of Child Neglect and Abuse

By Alicia R. Pekarsky, MD, State University of New York Upstate Medical University, Upstate Golisano Children's Hospital

Last full review/revision February 2018 by Alicia R. Pekarsky, MD 

 

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version

 

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Child neglect is withholding essential things from children. Child abuse is doing harmful things to children.

 

• Some factors that increase the risk of child neglect and abuse are poverty, drug and alcohol abuse, mental health disorders, and single parenthood.
  
• Children who are neglected or abused may appear tired, hungry, or dirty or have physical injuries or emotional or mental problems, or they may appear completely normal.
  
• Abuse should be suspected when the pattern of injury suggests that the injury was not accidental, when injuries do not match the caregiver's explanation, when children are not developmentally able to do things that could result in their injury (such as an infant turning on a stove), or when children have both healed and new injuries that do not appear accidental.
  
• Children should be protected from further harm by means that may include involvement of Child Protective Services and/or law enforcement agencies, hospitalization, counseling for parents and children, and assistance for the family in providing safe and appropriate care.
  

Neglect involves not meeting children's basic needs: physical, medical, educational, and emotional.

Abuse can be physical, sexual, or emotional. It can also involve child abuse in a medical setting.

Child neglect and abuse often occur together and with other forms of family violence, such as intimate partner abuse. In addition to immediate harm, neglect and abuse increase the risk of long-lasting problems, including mental health problems and substance abuse. Child abuse is also associated with problems in adulthood such as obesity, heart disease, and chronic obstructive pulmonary disease (COPD).

In 2015, 4.4 million reports of possible child abuse were made to Child Protective Services (CPS) in the United States, involving 7.2 million children. Of these reports, about 2.1 million were investigated in detail and about 683,000 abused or neglected children were identified. Boys and girls are affected equally. Infants and young children are at increased risk of abuse.

Of the children who were identified in 2015, 75.3% were neglected (including medical neglect), 17.2% were physically abused, 8.4% were sexually abused, and 6.9% were emotionally or otherwise abused. Many children were victims of multiple types of abuse.

In 2015, about 1,670 children in the United States died from neglect or abuse, about three quarters of whom were under 3 years of age. Over 70% of these children were victims of neglect and 44% were victims of physical abuse that occurred with or without other forms of abuse. More than 75% of perpetrators were parents acting alone or with other people. And about 25% of deaths were caused by the mother acting alone.

Risk factors for child neglect and abuse

Neglect and abuse result from a complex combination of individual, family, and social factors. Being a single parent, being poor, having problems with drug or alcohol abuse, and/or having a mental problem (such as a personality disorder or low self-esteem) can make a parent more likely to neglect or abuse a child. Also, adults who were physically or sexually abused as children are more likely to abuse their own children. Neglect is identified 12 times more frequently among children who are living in poverty than among children who are not.

First-time parents, adolescent parents, and parents who have several children under the age of 5 years are also at increased risk of abusing their children. Women who do not seek prenatal care, smoke, abuse drugs, or have a history of domestic violence while pregnant may be at risk of abusing their children.

Sometimes strong emotional bonds do not develop between parents and children. This lack of bonding occurs more commonly with premature infants or sick infants who are separated from their parents early in infancy or with biologically unrelated children (for example, stepchildren) and increases the risk of abuse.

Although physical abuse, emotional abuse, and neglect are associated with poverty and a lower social and economic status, all types of abuse, including sexual abuse, occur within all social and economic groups.

Types

There are a number of different types of child neglect and abuse. The types often occur at the same time.

 

Neglect

Neglect is the failure to provide for or meet a child’s basic physical, emotional, educational, and medical needs. Parents or caregivers may leave a child in the care of a person who is known to be abusive, or they may leave a young child unattended. There are many forms of neglect.

In physical neglect, parents or caregivers may fail to provide adequate food, clothing, shelter, supervision, and protection from potential harm.

In emotional neglect, parents or caregivers may fail to provide affection or love or other kinds of emotional support. Children may be ignored or rejected or prevented from interacting with other children or adults.

In medical neglect, parents or caregivers may not obtain appropriate care for the child, such as needed treatment for injuries or physical or mental health disorders. Parents may delay obtaining medical care when the child is ill, putting the child at risk of more severe illness and even death.

In educational neglect, parents or caregivers may not enroll the child in school or may not make sure the child attends school in a conventional setting, such as a public or private school, or in their home.

Neglect differs from abuse in that usually parents and caregivers do not intentionally mean to harm children in their care.

Neglect usually results from a combination of factors such as poor parenting, poor stress-coping skills, unsupportive family systems, and stressful life circumstances. Neglect often occurs in poor families experiencing financial and environmental stresses, particularly those in which parents also have mental health disorders (typically depression, bipolar disorder, or schizophrenia), abuse drugs or alcohol, or have limited intellectual capacity. Children in single-parent families may be at risk of neglect due to a lower income and fewer available resources.

Physical abuse

Physically mistreating or harming a child, including inflicting excessive physical punishment, is physical abuse. Specific examples include shaking, dropping, striking, biting, and burning (for example, by scalding or touching with cigarettes). Children of any age may be physically abused, but infants and toddlers are particularly vulnerable. Infants and toddlers are particularly at risk of repeated episodes of abuse because these children cannot speak for themselves. Also, during these periods, children are usually undergoing things that make it more likely that caregivers become frustrated and lose control of their impulses. Such frustrating things include temper tantrums, toilet training, inconsistent sleep patterns, and colic.

Physical abuse is the most common cause of serious head injury in infants. Abdominal injuries resulting from physical abuse are more common among toddlers than infants. Physical abuse (including homicide) is among the 10 leading causes of death in children. Generally, a child's risk of physical abuse decreases during the early school years.

Children who are born in poverty to a young, single parent are at highest risk of physical abuse. Family stress contributes to physical abuse. Stress may result from unemployment, frequent moves, social isolation from friends or family members, or ongoing family violence. Children who are difficult (irritable, demanding, or hyperactive) or who have special needs (developmental or physical disabilities) are more likely to be physically abused.

Physical abuse is often triggered by a crisis in the midst of other stresses. A crisis may be a loss of a job, a death in the family, or a discipline problem. Parents who use drugs or alcohol may behave impulsively and uncontrollably toward their children. Children whose parents have mental health problems are also at increased risk of being abused.

Parents who were neglected or abused as children may not be emotionally mature or may have low self-esteem. Abusive parents may see their children as a source of unlimited and unconditional affection and look to them for the support that they never received. As a result, they may have unrealistic expectations of what their children can provide for them, they may become frustrated easily and have poor impulse control, and they may be unable to give what they never received.

 

Sexual abuse

Any action with a child that is for the sexual gratification of an adult or a significantly older child is considered sexual abuse (see Pedophilia). It includes

• Penetrating the child's vagina, anus, or mouth
  
• Touching the child with sexual intention but without penetration (molestation)
  
• Exposing the abuser's genitals or showing pornography to a child
  
• Forcing a child to participate in a sex act with another child
  
• Using a child in the production of pornography
  

Sexual abuse does not include sexual play. In sexual play, children who are close in age view or touch each other's genital area without force or intimidation. When trying to determine whether a particular situation between children should be considered sexual abuse, it is important to take into account differences in power, such as the children's age, strength, size, and popularity status. Although there are no firm guidelines on what age difference distinguishes abuse from play, it would, for example, be inappropriate for a 12-year-old child to have sex with an 8-year-old child even if they both agreed to it. The greater the age difference, the greater the difference in emotional and intellectual maturity and social status between the older child and the younger child. And, at some point, these differences are so large that the younger child cannot legitimately be said to "agree" to activity with an older child.

By the age of 18, about 12 to 25% of girls and 8 to 10% of boys have been sexually abused. Most perpetrators of sexual abuse are people known by the children, commonly a stepfather, an uncle, or the mother's boyfriend. Female perpetrators are less common.

Certain situations increase the risk of sexual abuse. For example, children who have several caregivers or a caregiver with several sex partners are at increased risk. Being socially isolated, having low self-esteem, having family members who were also sexually abused, or being associated with a gang also increases the risk.

Emotional abuse

Using words or actions to psychologically mistreat a child is emotional abuse. Emotional abuse makes children feel that they are worthless, flawed, unloved, unwanted, in danger, or valuable only when they meet another person's needs.

Emotional abuse includes

• Harshly scolding by yelling or screaming
  
• Belittling the child's abilities and accomplishments
  
• Encouraging deviant or criminal behavior, such as committing crimes or abusing alcohol or drugs
  
• Bullying, threatening, or frightening the child
  

Emotional abuse tends to occur over a long period of time.

Child abuse in a medical setting

In this less common type of child abuse (previously called Munchausen syndrome by proxy and now called factitious disorder imposed on another), a caregiver intentionally tries to make doctors think that a healthy child is sick. The caregiver typically gives false information about the child's symptoms, for example, stating that the child has been vomiting or complaining of abdominal pain.

However, caregivers sometimes also do things to cause symptoms, for example, giving the child drugs. Sometimes, caregivers make it seem as though the child is sick by adding blood or other substances to specimens being used for laboratory tests.

 

Cultural factors

Different cultures have different ways to discipline children. Some cultures use corporal punishment, which is any punishment that is physical and causes pain. Severe corporal punishment, which includes whipping, burning, and scalding, is physical abuse. However, for lesser degrees of corporal punishment, such as spanking, the line between socially accepted behavior and abuse is blurred among different cultures. Some experts suggest that corporal punishment that is done in anger or to hurt the child or that results in visible injuries is not legitimate in any culture.

Medical practices also vary in different cultures. Certain cultural practices (such as female genital mutilation) are so extreme they constitute abuse. However, certain folk remedies (such as coining and cupping) often cause bruises or minor burns that can look as though they are the result of severe corporal punishment but are not.

Members of certain religious and cultural groups have sometimes failed to obtain treatment for a child who has a life-threatening disorder (such as diabetic ketoacidosis or meningitis), resulting in the child's death. Such failure is typically considered neglect regardless of the parents’ or caregivers’ intent. When children are ill and unhealthy, refusal of medical treatment often requires further investigation and sometimes legal intervention. Additionally, in the United States, certain people and cultural groups have increasingly been refusing to have their children vaccinated because they have concerns about safety or because of religious reasons. It is not clear whether this refusal of vaccination can legally be considered true medical neglect.

 

Symptoms

The symptoms of neglect and abuse vary depending partly on the nature and duration of the neglect or abuse, on the child, and on the particular circumstances. In addition to obvious physical injuries, symptoms include emotional and mental health problems. Such problems may develop immediately or later and may persist.

Sometimes children who are abused seem to have symptoms of attention-deficit/hyperactivity disorder (ADHD) and are mistakenly diagnosed with that disorder.

 

Physical neglect

Physically neglected children may appear undernourished, tired, or dirty or may lack appropriate clothing and may be failing to thrive. They may frequently be absent from school. In extreme cases, children may be found living alone or with siblings, without adult supervision. Unsupervised children may become ill or injured. Physical and emotional development may be delayed. Some neglected children die of starvation or exposure.

 

Physical abuse

Bruises, burns, welts, bite marks, or scrapes are some of the signs of physical abuse. These marks may have the shape of the object used to inflict them, such as a belt or lamp or extension cord. The children's skin may have handprints or round fingertip marks caused by slapping or grabbing and shaking. Cigarette or scald burns may be visible on the arms or legs or other parts of the body.

Children who have been gagged may have thickened skin or scarring at the corners of the mouth. Patches of hair may be missing or the scalp may be swollen in children whose hair has been pulled. Severe injuries to the mouth, eyes, brain, or other internal organs may be present but not visible. However, signs of physical abuse are often subtle. For example, a small bruise or reddish purple dots may appear on the face, neck, or both. Children may have signs of old injuries, such as broken bones, which have already begun to heal. Sometimes injuries result in disfigurement.

Toddlers who have been intentionally dunked into hot water (such as in a bathtub) may have scald burns. These burns may be located on the buttocks and may be shaped like a doughnut. Burns are not seen on skin that did not enter the water or that was pressed against the cooler bathtub floor. The splash of hot water may cause small burns on other parts of the body.

Infants may have brain injury resulting from what is now called abusive head trauma (AHT). AHT is caused by violent shaking and/or hitting the child's head against a firm object. Abusive head trauma has replaced the term "shaken baby syndrome" because more than shaking may be involved. Infants who have AHT may be fussy or have vomiting, or may have no visible signs of injury but appear to be sleeping deeply. This sleepiness is due to brain damage and swelling, which may result from bleeding between the brain and skull (subdural hemorrhage). Infants may also have bleeding in the retina (retinal hemorrhage) at the back of the eye. Ribs and other bones may be broken.

Children who have been abused for a long time may appear fearful and irritable. They often sleep poorly. They may be depressed and anxious and have symptoms of posttraumatic stress. They are more likely to act in violent or suicidal ways.

Sexual abuse

Changes in behavior are common signs of sexual abuse. Such changes may occur abruptly and may be extreme. Children may become aggressive or withdrawn or develop phobias or sleep disorders. Children who are sexually abused may show sexual behavior, such as touching themselves excessively, or touching others in ways that are not appropriate. Children who are sexually abused by a parent or other family member may have conflicted feelings. They may feel emotionally close to the abuser, yet betrayed.

Sexual abuse may also result in physical injuries. Children may have bruises, tears, or bleeding in areas around the genitals, anus, or mouth. Injuries in the genital and rectal areas may initially make walking and sitting difficult. Girls may have a vaginal discharge, bleeding, or itching. A sexually transmitted disease, such as gonorrhea, chlamydia, human immunodeficiency virus (HIV) infection, or other infections, may be present. Pregnancy may occur.

 

Emotional abuse and neglect

In general, children who are emotionally abused tend to be insecure and anxious about their attachments to other people because they have not had their needs met consistently or predictably. Other findings vary depending on the specific way children were emotionally abused. Children may have low self-esteem. Children who are terrorized or threatened may appear fearful and withdrawn.

They may be insecure, distrustful, unassertive, and extremely anxious to please adults. They may inappropriately reach out to strangers. Children who are not allowed to interact with others may be awkward in social situations and have difficulty forming normal relationships. Others may commit crimes or abuse alcohol, drugs, or both. Older children may not attend school regularly, may not do well when they attend, or may have difficulties in forming relationships with teachers and peers.

Infants who are emotionally neglected commonly fail to thrive and may seem unemotional or uninterested in their surroundings. Their behavior may be mistaken for intellectual disability or a physical disorder. Children who are emotionally neglected may lack social skills or be slow to develop speech and language skills.

 

Did You Know...

Most victims of sexual abuse know their abuser.

Diagnosis

• A doctor's examination
  
• Photographs of injuries
  
• For physical abuse, sometimes laboratory tests or imaging tests such as x-rays and computed tomography (CT) scans
  
• For sexual abuse, testing for infections and sometimes collection of samples of body fluids, hair, and other material for evidence
  

Neglect and abuse are often difficult to recognize unless children appear severely undernourished or are obviously injured or unless neglect or abuse is witnessed by other people. Neglect and abuse may not be recognized for years. There are many reasons why neglect and abuse go unrecognized. Abused children may feel that abuse is a normal part of life and may not mention it. Physically and sexually abused children are often reluctant to volunteer information about their abuse because of shame, threats of retaliation, or even a feeling that they deserve the abuse. Physically abused children who are able to speak well often identify their abuser and describe what happened to them if asked directly. However, sexually abused children may be sworn to secrecy or so traumatized that they are not able to talk about the abuse and may even deny abuse when specifically questioned.

When doctors suspect neglect or any type of abuse, they look for signs of other types of abuse. They also fully evaluate the physical, environmental, emotional, and social needs of the child. Doctors observe interactions between the child and the caregivers whenever possible. Doctors document the child's history by writing down exact quotes and taking pictures of any injuries.

 

Neglect and emotional abuse

A neglected child may be identified by health care practitioners during an evaluation for an unrelated issue, such as an injury, an illness, or a behavioral problem. Doctors may notice that a child is not developing physically or emotionally at a normal rate or has missed many vaccinations or appointments. Teachers and social workers are often the first to recognize neglect. Teachers may identify a neglected child because of frequent unexplained absences from school.

Emotional abuse is usually identified during evaluation for another problem, such as poor performance in school or a behavioral problem. Children who are emotionally abused are checked for signs of physical and sexual abuse.

 

Physical abuse

Physical abuse may be suspected when an infant who is not yet cruising (walking by holding on to furniture) has bruises or serious injuries or seemingly minor injuries to the face and/or neck. Infants who are uncharacteristically sleepy or lethargic are evaluated for brain injury. Abuse may be suspected when a toddler or older child has bruises in unusual locations, such as on the back of the legs and buttocks. When children are learning to walk, bruises often result, but such bruises typically occur on prominent bony areas on the front of the body, such as the knees, shins, chin, and forehead.

Abuse may also be suspected when parents seem to know little about their child's health or seem unconcerned or overly concerned about an obvious injury. Parents who abuse their child may be reluctant to describe to the doctor or friends how an injury occurred. The description may not fit the age and nature of the injury or may change each time the story is told. Abusive parents may not immediately seek treatment for a child's injury.

Rib Fractures in a Baby

PHOTOSTOCK-ISRAEL/SCIENCE PHOTO LIBRARY

If doctors suspect physical abuse, they usually take photographs of the injuries. Doctors may do imaging of the brain (a computed tomography [CT] scan or magnetic resonance imaging [MRI]). Sometimes x-rays are taken to look for signs of previous injuries. Often, if a child is younger than 3 years, x-rays of all bones are taken to check for fractures.

Sexual abuse

Often, sexual abuse is diagnosed on the basis of the child's or a witness's account of the incident. However, because many children are reluctant to talk about sexual abuse, it may be suspected only because the child's behavior becomes abnormal. Doctors should suspect sexual abuse if a young child has a sexually transmitted disease.

If a child has been sexually abused within 96 hours of arrival at a medical facility, doctors examine the child to collect legal evidence of possible sexual contact, such as swabs of body fluids and skin surfaces. This collection of evidence often uses what is known as a rape kit. Photographs of any visible injuries are taken. In some communities, health care practitioners who are specially trained to evaluate sexual abuse of children do this examination. Doctors typically also do tests for sexually transmitted diseases and, when appropriate, for pregnancy.

Prevention

The best way to prevent child abuse and neglect is to stop it before it starts. Programs that provide support for parents and teach positive parenting skills are very important and necessary. Parents can learn how to communicate positively, discipline appropriately, and respond to their children’s physical and emotional needs. Programs to prevent child abuse and neglect also help improve parent-child relationships and provide parents with social support.

These support programs for parents may be held in parents’ homes, in schools, in medical or mental health clinics, or in other community-based settings. Programs may involve one-on-one or group sessions.

 

Treatment

• Treatment of injuries
  
• Measures to ensure safety of the child, sometimes including removal from the home
  

All physical injuries and disorders are treated. Some children are hospitalized for treatment of injuries, severe undernutrition, or other disorders. Some severe injuries require surgery. Infants who may have abusive head trauma are usually admitted to the hospital. Sometimes healthy children are hospitalized to protect them from further abuse until a safe place can be ensured. Physical abuse, particularly head trauma, can have long-lasting effects on development. All children with head trauma should be evaluated because they may need early intervention services, such as speech and language therapy and occupational therapy.

Some children who have been sexually abused are given drugs to prevent sexually transmitted diseases, sometimes including HIV infection. Children who are suspected of being abused need immediate support. Sexually abused children, even those who appear unaffected initially, are referred to a mental health care practitioner because long-lasting problems are common. Long-term psychologic counseling is often needed. Doctors refer children with other types of abuse for counseling if behavioral or emotional problems develop.

Immediate safety of the child

Doctors and other health care practitioners who have contact with children are required by law to promptly report cases of suspected child neglect or abuse to Child Protective Services. Health care practitioners should, but are not required to, tell parents that a report is being made according to the law and that they may be contacted, interviewed, and likely visited at their home. Depending on the circumstances, the local law enforcement agency may also be notified. Prompt reporting is also required from all people whose job places children younger than 18 in their care. Such people include teachers, child care workers, foster care providers, and police and legal services personnel. Anyone else who knows of or suspects neglect or abuse is encouraged to report it but is not required by law to do so. Any person who makes a report of abuse based on reasonable cause and in good faith cannot be arrested or sued for their action. People can report abuse or get help by contacting the National Child Abuse Hotline at 1-800-4-A-CHILD (1-800-422-4453).

Reported cases of child abuse are screened for the need for further investigation. Reported cases that require further investigation are investigated by representatives of the local Child Protective Services agency, who determine the facts and make recommendations. Agency representatives may recommend social services (for the child and family members), temporary hospitalization for protection, temporary placement with relatives, or temporary foster care. Doctors and social workers help the representatives from the Child Protective Services agency decide what to do based on the immediate medical needs of the child, the severity of the injuries, and the likelihood of further neglect or abuse.

Follow-up care

A team of doctors, other health care practitioners, and social workers attempts to address the causes and effects of neglect and abuse. This team works together with the legal system to coordinate care for the child. The team helps family members understand the child's needs and helps them access local resources. For example, a child whose parents cannot afford health care may qualify for medical assistance from the state. Other community and government programs can provide assistance with food and shelter. Parents with substance abuse problems or mental health problems may be directed to appropriate treatment programs. Parenting programs and support groups are available in some areas. Periodic or ongoing contact by a social worker, a victim's advocate, or both may be needed for the family.

Removal from the home

The ultimate goal of Child Protective Services is to return children to a safe, healthy family environment. Depending on the nature of the abuse and other factors, children may go home with their family members or may be removed from their home and placed with relatives or in foster care situations where caretakers are capable of protecting the child from further abuse. This placement is often temporary, for example, until the parents obtain housing or employment or until regular home visits by a social worker are established. Unfortunately, recurrences of neglect and/or abuse are common. In severe cases of neglect or abuse, long-term removal may be considered or the parents' rights may be permanently terminated. In such cases, the child remains in foster care until the child is adopted or becomes an adult.

More Information

• Childhelp National Child Abuse Hotline (1-800-4-A-CHILD)
  
• The Kempe Foundation for the Prevention and Treatment of Child Abuse and Neglect
  
• National Parent Helpline (1-855-4-A-PARENT)
  

 

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version