health care providers develop expertise to appropriately assess and recognize all types of child abuse and neglect and intervene

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.

Child Neglect

Definition and Identification

Child neglect involves acts of omission by adult caregivers.

There are four subtypes of neglect:

out needed health care, abandonment, lack of supervision,

and failure to provide for a child’s basic needs of

nutrition, clothing, hygiene, and safety

Developmental Delay

• Emotional neglect:

refusal to obtain or delays in seeking

psychological care, inadequate attentionto a child’s

needs for affection, emotional support, or attention, or

exposure of the child to extreme domestic violence and

permitting a child’s maladaptive behaviors

• Educational neglect:

 permitting chronic truancy, failure

to enroll a child in mandatory schooling, and inattention

to a child’s special needs

Prevalence

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.

Physical Abuse

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, in

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.

Prevalence

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.

Sexual Abuse

Definition and Identification

Sexual abuse is identified as any sexual activity by an adult

with a child where consent is either not given or cannot be

given. In addition, sexual activity by an older child with a

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. Sexual

abuse can include voyeurism, showing children sexually

explicit materials, or actual sexual penetration with penis,fingers,

or objects. Regardless of the child’s age, incest is illegal.

Prevalence

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 or

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 “doserelated”

responses of chronic versus acute maltreatment.

Child Neglect

Children that experience abuse or neglect may exhibit a

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) and

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 or

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 be

toward adults or peers and persists through the lifespan

without intervention. Physically abused children also may

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 to

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 disorder

(PTSD).

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.

Information From:

CHILD ABUSE AND NEGLECT:

ISSUES FOR NEUROLOGISTS

EVE G. SPRATT, MD

CYNTHIA CUPIT SWENSON, PHD