Child abuse is defined by the Child Abuse Prevention and Treatment Act (CAPTA) as “Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act that presents an imminent risk of harm.” There are four major types of maltreatment: neglect, physical abuse, psychologic mal-treatment, and sexual abuse. Most states set up their own guidelines indicating the level of evidence to make the distinguishing finding or disposition for the abuse.
|FRACTURES IN ABUSED CHILDREN|
The National Child Abuse and Neglect System (NCANDS) of the Administration of Children, Youth, and Families (ACYF) Annual Report 2009 indicates that there were 9.3 unique abuse victims confirmed per 1,000 children in the United States. Children 1 year and younger had the highest rate of victimization; there was an almost equal distribution of boys and girls; some children experienced multiple abuses. Neglect was most frequent (78.3%), followed by physical abuse (17.8%). Sexual and psychologic maltreatment each occurred in 10% of abused children overall. The 2009 national fatality rate was 2.34 per 100,000 and has been increasing over the past 5 years. Health and mental health-care professionals should maintain the possibility of abuse on their differential every time they see a child.
Clinical Presentation. Presentations vary greatly depending on the type(s) of abuse as well as social and emotional developmental stage. Children with developmental disabilities, that is, mental retardation, emotional disturbances, visual or hearing impairment, learning disabilities, physical disabilities, behavior problems, or other medical problems are at increased risk of being victims.
Physical abuse most often manifests with signs of abuse, including bruising and/or skeletal injury. In addition, physical abuse is often associated with psychologic impacts, including increased anger, aggression, poor academic performance, sleep problems, drug abuse, and suicidality. Sexually abused children often present to physicians for evaluation of genital injury. The sequelae includes impaired mental health with increase in rates of depression, anxiety disorders, sleep disorders, suicide attempts, and posttraumatic disorder (PTSD), but not schizophrenia or somatoform disorders.
With psychologic abuse, it is more difficult to quantify and identify consistent patterns of presentation. Children of psychologic abuse present with increased levels of depression, academic difficulties, aggression, and behavior problems. Often, children are exposed to more than one type of abuse, and so the impact of abuse can be complex. In addition, physical, sexual, and psychologic abuse are associated with poor self-esteem, personality disorders, and impaired interpersonal relationships.
Diagnosis. Evaluations must be carried out by qualified pediatric health-care professionals, such as child and adolescent psychiatrists, pediatricians, child psychologists, child-trained social workers, pediatric counselors, and clinical nurse specialists, depending on the type of abuse—physical and/or psychologic. If there is a concern about physical abuse, physical and diagnostic examinations should be performed as soon as abuse is suspected. With concern about sexual abuse, pregnancy tests and/or sexually transmitted infections must be evaluated. In all instances, information should be gathered from multiple people within the child’s psychosocial sphere (e.g., parents/caregivers, family members, teachers, counselors).
Treatment. The first step after identification of suspected abuse is reporting to a child protective service (CPS) agency. The CPS will carry out a thorough investigation of the suspected person(s) abusing the child and their living situation. The CPS will engage a treatment team to support the child and his or her family. In instances where the child’s safety has been compromised and/or future abuse is suspected without intervention, then the child may be placed in a safe environment until the investigation is complete or sufficient supports are put in place for the child to return home. The primary treatment for child abuse includes psychotherapy, which can include components of cognitive-behavioral therapy (change behavior by addressing distorted cognitions), behavioral and learning therapy (modifying habitual responses to situations/ stimuli), family therapy (explore patterns of family interactions), and developmental victimology (describes the processes involved in the onset and maintenance of abusive behavior).
Course. Child abuse is hypothesized to mediate response biases, resulting in impaired emotional and cognitive regulation. Adult victims of prior childhood abuse are found to have higher rates of sleep disorders, abdominal disorders, obesity, chronic pain (e.g., head-ache, back ache, premenstrual syndrome), fatigue, and exaggerated startle responses. Longitudinal studies indicate that adults continue to suffer from low self-esteem, maladaptive sexual behavior, and impaired interpersonal relationships (e.g., parenting, romantic/ intimate). Despite these findings, not every child who experiences abuse develops these symptoms, indicating a role for protective factors, such as cognitive factors, meaningful relationships, and the impact of treatment interventions.