Child maltreatment is the most common cause of preventable developmental and psychiatric
disorders. It is essential that pediatric
health care providers develop expertise to appropriately assess and recognize all types
of child abuse and neglect and intervene
refer cases as appropriate. Biologic research is leading to a greater understanding
Definitions and Prevalence
Health professionals are required to report suspected child
abuse or neglect to the state Child Protective Services (CPS)
agency. Failure to do so can result in criminal prosecution.
Professionals who are mandated reporters do not have to
wait to report abuse until it reaches a certain definition or
criteria; they must simply report suspected abuse. Once an
abuse report is made,CPS determines whether the event or
injury meets an abuse definition. Such definition varies by
state. In the following sections, we discuss common definitions
of different types of child abuse and neglect, although
there is no broadly accepted national definition.
Definition and Identification
Child neglect involves acts of omission by adult caregivers.
There are four subtypes of neglect:
Physical neglect: refusal to provide or delays in seeking
out needed health care, abandonment, lack
and failure to provide for a child’s basic needs of
nutrition, clothing, hygiene, and safety
• Medical neglect: a delay in obtaining or failure to seek obtaining or failure to seek
refusal to obtain or delays in seeking
psychological care, inadequate attentionto a child’s
needs for affection, emotional support, or attention,
exposure of the child to extreme domestic violence and
permitting a child’s maladaptive behaviors
permitting chronic truancy, failure
to enroll a child in mandatory schooling, and inattention
to a child’s special needs
Child neglect is the most common form of maltreatment,
leading to one-third of all child fatalities.Neglect accounts
for 45 to 55% of reported maltreatment cases.
Definition and Identification
The definition of physical abuse generally includes intentional
injury to a child less than 18 years of age by an adult.
Types of injuries involve bruises, welts, fractures, burns,
bites, poisoning, internal injuries, drowning, smothering,
gagging, shaking, and cutting. Special subtypes include
substance use in utero; factitious disorder by proxy,
which a parent induces or fabricates an illness or physical
or psychological symptom in an otherwise healthy child;
shaken baby syndrome, which is not always easily identified
and can result in death; and parent-induced apnea,
mistaken as sudden infant death.
Roughly 25% of reported maltreatment cases are for physical
abuse. The congressionally mandated Third National
Incidence Study of Child Abuse and Neglect indicated that
381,700 children were physically abused in 1993.
Definition and Identification
Sexual abuse is identified as any sexual activity by an
with a child where consent is either not given or cannot
given. In addition, sexual activity by an older child
younger child can be considered sexual abuse if there
is a significant
difference in age (generally 5 years), development, or
size, and the younger child is unable to give consent.
abuse can include voyeurism, showing children sexually
explicit materials, or actual sexual penetration with
or objects. Regardless of the child’s age, incest
Most sexual abuse is not reported, so establishing prevalence
rates is difficult. National surveys have revealed that
20 to 25% of girls and 5 to 15% of boys experience some
form of sexual abuse.
Multiple Abuse Experiences
Most frequently, victims of child abuse and neglect are
subjected to multiple types of maltreatment. Child neglect
is the most common form of child maltreatment, yet little
is known about the consequences of neglect in the presence
or absence of other forms of maltreatment (eg, physical
sexual abuse). In some states, cases are recorded as neglect,
as doing so may prevent court involvement required in
cases with suspicions of physical and sexual abuse.
One of the primary dangers of not distinguishing pure
types of maltreatment from mixed groups is that effects
attributed to a particular form of maltreatment (eg, sexual
abuse) may be overestimated, underestimated, or misattributed
to the inclusion of children in a group who have
also experienced other forms of maltreatment. Little attention
has been paid to distinguishing developmental effects
of single versus multiple forms of maltreatment or to
responses of chronic versus acute maltreatment.
Children that experience abuse or neglect may exhibit
variety of emotional or behavioral problems across multiple
domains. Neglected children mainly show difficulties
in social and physical development. Physical development
problems may include failure-to-thrive syndrome in
infants, indicated by growth delay with postural signs
(poor muscle tone, persistence of infantile postures)
behavioral signs (unresponsive, minimal smiling, few
vocalizations). Delays in cognitive functioning may include
deficits in language, academic delays, and lowered intelligence
scores. Delays in social or behavioral development
may be manifested through avoidant or resistant attachment
to the primary caregiver, passivity, reduced play
interactions with mothers, isolative play in preschoolers
school-aged children, and an increased risk for delinquency
and criminal behavior in adolescents. Some of
these youngsters attach “too eagerly” to a
health care professional
because they are so hungry for love and attention.
Child Physical Abuse
The most common behavior related to the experience of
child physical abuse is aggression. The aggression can
toward adults or peers and persists through the lifespan
without intervention. Physically abused children also
show poor social competence in making friends and personal
problem-solving. For infants, there may be a tendency
to have an insecure attachment to the caregiver and
later difficulties sustaining relationships. With regard
cognitive functioning and academic performance, physically
abused children tend to score lower on intelligence tests
because of expressive and receptive language deficits.
In school, they show lower achievement than nonabused
peers and also exhibit school discipline problems. Finally,
physically abused children may show emotional difficulties
such as depression, anxiety, and posttraumatic stress
Child Sexual Abuse
As with other forms of abuse, a wide range and array of
outcomes is associated with childhood sexual victimization.
The sequelae associated with sexual abuse covers the
entire spectrum of mental health problems, but when
symptoms are present, they vary by developmental level.
Preschoolers are more likely to show anxiety symptoms,
nightmares, PTSD, internalizing and externalizing behaviors,
and sexual acting out. School-aged children are more
likely to experience fears, aggression, and school problems.
Adolescents are more prone to depression, withdrawal,
suicidal or self-injurious behavior, somatic complaints,
illegal acts, running away, or substance abuse.
CHILD ABUSE AND NEGLECT:
ISSUES FOR NEUROLOGISTS
EVE G. SPRATT, MD
CYNTHIA CUPIT SWENSON,