Nurses Need to Know the Indicators of Child Abuse

June 28th, 2012

By Jennifer Olin, BSN, RN

Child abuse and neglect stories often capture our attention in the news. The Jerry Sandusky Trial, the continuing trials of the Catholic Church, and all those local stories we each hear in our own hometowns.

While this is not a new phenomenon, the stressors of a poor economy and unemployment lend to the frequency of abuse. As nurses, it is one of our jobs, one of our responsibilities, to step in and report abuse and neglect when we suspect it.

Federal legislation lays the groundwork for identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act (CAPTA), as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect as, at minimum:

• Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation
• An act or failure to act which presents an imminent risk of serious harm.

Within the minimum standards set by CAPTA, each state is responsible for providing its own definitions of child abuse and neglect. Most states recognize four major types of maltreatment: physical abuse, neglect, sexual abuse, and emotional abuse. Although any of the forms of child maltreatment may be found separately, they often occur in combination.

Major Types of Child Abuse and Neglect

Physical abuse is the non-accidental physical injury (ranging from minor bruises to severe fractures or death) as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise harming a child, that is inflicted by a parent, caregiver, or other person who has responsibility for the child. Common indicators of physical abuse include:

• Pattern bruises or scars
• Symmetric immersion burns
• Pattern contact burns
• Bruises or burns on a non-ambulating infant
• Multiple injuries in different stages of healing
• Bruises on earlobes
• Subdural hemorrhage
• Liver or kidney laceration
• Pancreatic injury
• Scapular fractures
• Fractures of different ages
• Bite marks
• Any injury not consistent with history provided by the adult or the child

These injuries are all considered abuse whether or not the caregiver intended to hurt the child. Physical discipline, such as spanking or paddling, is not considered abuse as long as it is reasonable and causes no bodily injury to the child.

Neglect is the failure of a parent, guardian, or other caregiver to provide for a child's basic needs. Neglect may be:

• Physical – This includes failure to provide necessary food or shelter, or lack of appropriate supervision.
• Medical – Simply the failure to provide necessary medical or mental health treatment.
• Educational – The failure to educate a child or attend to special education needs.
• Emotional – Inattention to a child's emotional needs, failure to provide psychological care, or permitting the child to use alcohol or other drugs.

Common indicators of neglect include:

• Persistent hunger
• Stealing or hoarding food
• Abrupt, dramatic weight change
• Persistent poor hygiene
• Recurring untreated medical issues
• Ongoing lack of supervision
• Consistently inappropriate dress
• Excessive school absences

Sexual abuse is defined by CAPTA as "the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children."

Common indicators of sexual abuse
 and sexual exploitation include:

• Age-inappropriate knowledge of sexual behavior
• Sexually explicit drawings and behavior
• Unexplained fear of a person or place
• Unexplained itching, pain, bruising, or bleeding in the genital area
• Age-inappropriate seductive behavior
• Pregnancy
• Venereal disease, frequent urinary, or yeast infections
• Laceration of the hymen, missing segment of hymenal tissue
• Perianal lacerations extending deep to the external sphincter
• Laceration or bruising of labia, penis, scrotum, perianal tissues, or perineum

Emotional abuse (or psychological abuse) is a pattern of behavior that impairs a child's emotional development or sense of self-worth. This may include constant criticism, threats, or rejection, as well as withholding love, support, or guidance.

Emotional abuse is often difficult to prove and, therefore, child protective services may not be able to intervene without evidence of harm or mental injury to the child. Emotional abuse is almost always present when other forms are identified.

Abandonment and parental substance abuse are now defined in some states as other forms of abuse and neglect. Examples include:

• Prenatal exposure of a child to harm due to the mother's use of an illegal drug or other substance.
• Manufacture of methamphetamine in the presence of a child.
• Selling, distributing, or giving illegal drugs or alcohol to a child.
• Use of a controlled substance by a caregiver that impairs the caregiver's ability to adequately care for the child.

The lists here are just some of the more common indicators of abuse and neglect. They are not exhaustive. Use common sense, and always err on the side of caution by filing a report when in doubt.

Child maltreatment is a significant public health problem in the United States. More than 700,000 children are confirmed as abused and neglected by Child Protective Services (CPS) each year. These confirmed cases, however, represent only a fraction, not the true magnitude, of the problem.

The definitions of child abuse and neglect may be a challenge to apply to a particular circumstance. Most importantly, it is our job as nurses to make sure the smallest suspicions are reported and not our job to determine whether these legal standards are met. If you suspect that a patient meets the criteria of theses circumstances you MUST file a report with your local authorities.