Introduction

Child abuse and neglect is defined in federal legislation as “any recent act or failure to act on the part of a parent or caregiver 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 serious harm.” This term typically encompasses neglect, physical abuse, sexual abuse, medical child abuse (formerly Munchausen by Proxy), and psychological maltreatment. However, the definition has expanded to include drug-endangered children and the commercial sexual exploitation of children (i.e., sex-trafficking).

Number of Cases of Child Abuse in the United States in 2020

(Reference: Child Maltreatment 2021. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families Children’s Bureau 2021.

Approximately 600,000–700,000 cases of child maltreatment are reportedly annually in the United States, with 75% of reports related to neglect, 15% to physical abuse, and 10% to sexual abuse. Any child may experience child maltreatment. However, rates of victimization are highest in children younger than 1 year due to their vulnerability. High rates are also reported in American Indian/Alaska Native and African American children, likely reflecting the intersection of structural racism, economic stress, and the child welfare system.

Victims by Age, 2021

(Reference: Child Maltreatment 2021. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families Children’s Bureau 2021.)

Given the substantial health burden associated with child maltreatment and the risk for repeated abuse, prompt recognition and diagnosis are critical. This requires a careful history that elucidates the reported mechanism of injury in the context of a child’s developmental capabilities and a thorough physical examination. Further medical evaluation may be appropriate to identify occult injuries or medical conditions that predispose a child to injury or mimic abuse (e.g., when a child presents with unexplained bruising, differential diagnosis should include bleeding disorders).

Documentation: Many victims of abuse are too young, too ill, or too scared to disclose the abuse they have sustained, and, when required, interviewing children should be done in a sensitive, trauma-informed manner. However, investigative or forensic interviewing is not the role of the general medical provider and should be deferred to trained specialists. Therefore, medical providers should limit questions to the minimal facts necessary to provide appropriate medical care. Documentation of presentation to care should strive to include endorsements of trauma, denials of trauma, and detailed descriptions of trauma history provided by victims or their caregivers. Of note, medical charting is a medicolegal document in all situations, including cases in which there is concern for child maltreatment.

Mandatory reporting: Physicians in all states are mandated by law to report suspected child abuse and neglect to the local child protective services or law enforcement agency.

This rotation guide covers the following topics:

• Neglect

• Physical Abuse

• Sexual Abuse

• Medical Child Abuse

• Sex Trafficking

• Drug-Endangered Children

• Legal Mandates for Health Care Providers
  
  

Other topics related to child abuse and maltreatment are covered in the following rotation guides:

• Trauma (Pediatric Emergency Medicine)

• Adverse Childhood Experiences and Social Determinants of Health (Preventive/Well Child Care)

• Sexually Transmitted Infections (Adolescent Care)