Child physical abuse occurs when a child is injured due to intentional or unintentional acts by a caregiver and includes injuries from hitting, kicking, punching, biting, throwing, shaking, stabbing, choking, burning, or any other act that physically harms a child. The acts may be unintentional in that the parent may not have purposely hurt the child, but nonetheless an injury occurred. Child abuse and neglect is defined in federal law in the Child Abuse Prevention and Treatment Act or CAPTA (42 U.S.C.A. §5106g), amended by the Keeping Children and Families Safe Act of 2003, as at a 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; or an act or failure to act which presents an imminent risk of serious harm.” Individual state statutory definitions of physical abuse are derived from the federal definition of child abuse and neglect and vary, but most states’ definitions of physical abuse include a statement that the act resulted in some type of physical injury or mark on the child. For example, it is within a caregiver’s rights to spank a child, but if this disciplinary technique leaves physical marks, it is considered physical abuse. Researchers estimate that approximately 20% of all maltreatment cases can be categorized as physical abuse. Neglect comprises about 60%, sexual abuse about 10%, and emotional maltreatment and other forms make up the balance of all maltreatment cases.
Evaluation of physical abuse should consider a careful examination of the circumstances surrounding the event, the family history, and family and community culture. More specifically, evaluation considers the following:
- What harm occurred to the child?
- What is the child’s age and developmental level?
- Were the acts or behaviors based upon lack of information, or carelessness, or were they intentional?
- What were the circumstances surrounding the event and/or behaviors?
- What is the child’s interpretation of the event and/or behaviors?
- What are the community and family standards and practices regarding the event?
- What is the caregiver and family history regarding similar events and risk factors?
Physical abuse can be categorized into subtypes that correspond to the type of injury experienced by the child. The major subtypes are discussed next.
Cutaneous injuries are injuries that occur on the cutaneous areas, or skin, of the child’s body. Typically these marks are bruises, abrasions, cuts, and other marks to the skin. Physical bruising is the most typical type of physical abuse injury. Sometimes, the outline of the implement that was used to create the injury can be seen on the skin. For example, a belt, switch, or hand may leave a clearly identifiable pattern on the skin. Marks caused by physical abuse are typically seen on the fleshy areas of the body, such as the buttocks, back, and thighs, while accidental injuries are typically found on bony prominences, such as knees, shins, and foreheads, as these are the body parts that first come into contact with the ground or a piece of furniture when a child falls or runs into a stationary or immovable object. Other cutaneous injuries include bite marks, circumferential marks around the ankles or wrists when a child has been tied up, and strap and switch marks.
Cutaneous injuries should be carefully assessed to distinguish them from injuries caused by accidents, naturally occurring conditions, or cultural practices. Naturally occurring cutaneous marks include Mongolian spots (grayish blue spots usually on the buttocks, backs, legs, upper arms, and shoulders), salmon patches (pink marks on the neck, eyelids, nose, or forehead of newborns), and strawberry marks (not present at birth but appearing 4–6 weeks later). Folk healing practices may also be mistaken for maltreatment. For example, a practice called “coining,” which originated in Southeast Asia to treat fever and other maladies, involves rubbing the skin with a coin, which leaves long, linear bruises that may be mistaken for marks of abuse. Careful assessment of any cultural practice should consider the child’s interpretation of the event, the cultural meaning behind the practice or incident, and the resulting injury.
Burn injuries are classified by the cause of the wound and include immersion, splash, electrical, object, and chemical burns. When assessing a burn, the history and story given by the caretaker provides key information to determine if the burn was accidental or intentional, but even if it was accidental, the situation should be assessed for neglect issues. Evaluation of all burns should assess who was involved in the incident, the child’s developmental maturity, when the event occurred, when medical attention was sought, and the specific circumstances surrounding the event. Maltreatment should be considered when the history is incompatible with the physical findings, the developmental age of the child makes the sequence of events unlikely, and the burn is older than indicated by the historical account. Safety issues should be considered even when the burn was accidental.
Burns are typically categorized as superficial, partial thickness, or full thickness, with full thickness impacting the entire thickness of the skin and requiring more intensive treatment. The extent of the burn is also considered when determining severity, with burns covering a higher percentage of the body considered more severe. Immersion burns are the most frequently seen types of abusive burns and occur when a child’s body or body part is held in scalding water, usually as some form of punishment. An immersion burn will have clear lines of demarcation, while an accidental immersion burn will present a more ragged appearance. Other types of burns include splash burns, when a hot liquid comes into contact with the skin, for example, a pot of boiling water that is knocked over; and contact burns, when a hot object touches the skin, such as a cigarette, curling iron, stove burner, or heater grate. Electrical burns most often occur when a young child mouths an electrical cord or socket.
Injuries To The Head, Eyes, Ears, Nose, And Face
Head injuries may occur on the skull, spine, neck, and the face. A subdural hematoma or hemorrhage may result from a head injury and results when bleeding occurs between areas in the brain. Shaken baby syndrome or shaken impact syndrome describes a constellation of symptoms that occur when a child is shaken, causing the child’s head to experience severe acceleration, deceleration, and/or rotational force. Head injuries require a complete physical evaluation of physical symptoms including neurological functioning.
Evaluation compares the circumstances and history of the injury with the story given for how it occurred. Eye injuries can result from a blow to the eye or occur in conjunction with a head injury causing a retinal hemorrhage. Ear injuries may be caused by direct blows to the ear, grabbing, or a penetrating trauma, and may result in bruising, abrasions, and perforation of the inner ear. Nasal injuries may result from blunt trauma to the nose. A penetrating trauma can cause injury to the nasal septum. Oral injuries may be more common because of the significance of the mouth for communication and eating, which can be seen as sources of conflict by caregivers. Frenulum tears (i.e., tears to the small folds of skin that connect the lips to the gums and connect the tongue to the floor of the mouth) should generate high suspicion of abuse. Traumatic injury to the baby teeth of young children can be quite common in accidental or abusive injuries. All potentially abusive injuries should consider the history and child’s developmental level.
Abusive fractures are discerned typically by assessing the type and age of the fracture and the history given about how the fracture occurred. When abusive fractures are suspected, a full skeletal survey may be conducted to determine the presence of current or old fractures. Types of fractures include closed (a fracture with no skin wound), complicated (a broken bone also injured an internal organ), compound (the broken bone protrudes through the skin), compression (the bone collapses along the direction of the force), hairline (a minor fracture), impacted (the broken bone is wedged into the interior of another), and spiral (a slanting, diagonal fracture often caused by twisting). Organic abnormalities or genetic conditions should be ruled out before determining that a fracture is maltreatment.
Injuries to the thoracic and abdominal organs can be lethal and typically occur as the result of blunt trauma or being thrown down. Often, there is no external bruising, so diagnosis depends upon a detailed history. Abdominal injuries may include injuries to the liver, pancreas, spleen, stomach, small intestine, large intestine, or kidneys. Thoracic or chest injuries also occur as the result of blunt trauma or being thrown. Chest injuries may result in injury to the throat, rib cage, heart, or lungs. Any injury to the abdomen or chest requires immediate evaluation due to the lethality potential.
Poisoning occurs when a caregiver harms a child by inducing the child to take a poisonous substance or a substance taken in sufficient quantity that it becomes poisonous, and whether it is given as a punishment or for a well-intentioned reason. For example, as punishment for soiling, the caregiver may force the child to induce large quantities of water, creating an electrolyte imbalance that leads to brain swelling. Alternatively, caregivers may give a child drugs that were prescribed for themselves, such as barbiturates or antihistamines, to sedate a child whom the caregiver perceives as fussy or otherwise troublesome. Other substances that can be poisonous include table salt, hot peppers, black pepper, or laxatives. Accidental poisoning may occur when hazardous chemicals or other harmful substances are improperly stored or open and the child gets into them and ingests the poison. Supervisional neglect should be considered in those instances when chemicals or other hazardous materials are left accessible to small children.
Pediatric Condition Falsification
Formerly called Munchausen’s Syndrome by Proxy, this condition has been renamed to more accurately reflect the syndrome. This abusive parenting disorder occurs when a parent purposely induces or fabricates injuries or conditions to a child that result in unnecessary and sometimes even painful tests and hospitalization. The parent conceals his or her role in inducing or faking the injuries. These conditions in and of themselves are detrimental and even dangerous to the child—for example, smothering a child to simulate sleep apnea or breathing issues, or inducing vomiting. Often, the symptoms subside when the child is separated from the perpetrating caregiver. Typically, the child’s mother is the perpetrator and does this as an attention-seeking behavior. Diagnosis usually occurs after conventional treatments do not work, there are no corresponding rational reasons for their ineffectiveness, and the deceptive story surrounding the child and his or her illnesses and conditions starts to unravel.
Treatment For Physical Abuse
An understanding of the contributing factors to child physical abuse influences the selection of prevention and treatment strategies. Since contributing factors to physical abuse may be different for every person, interventions must be closely linked to a comprehensive assessment and individualized according to the risk factors identified during the assessment process. Some parents or caregivers may have totally unrealistic expectations regarding a child’s crying, eating difficulties, or toilet training. In situations like these, educational and supportive approaches may be most effective. Other parents or caregivers may understand the developmental levels and needs of a child, but lack skills in self-control and managing their own anger. Parenting education will likely not reduce the risk of future maltreatment if the cause of physical abuse is lack of impulse control. Anger management or therapy to address underlying issues related to the uncontrollable rage is an appropriate intervention. Sometimes a parent’s or caregiver’s anger is a symptom of untreated depression or substance abuse. Even when such conditions are treated, there may be adverse effects of medication, such as increased agitation or anxiety, that are expressed as an inability to handle normal stresses of parenting. Interventions appropriate when lack of parenting skills is identified as a cause of child physical abuse include the following:
- Programs offering instruction in specific parenting skills such as discipline methods, basic child care, and infant stimulation
- Child development education
- Local support services and linkages to other parents in the community
- Increasing the parent’s or caregiver’s knowledge of child development and the demands of parenting
- Enhancing the parent’s or caregiver’s skill in coping with the stresses of infant and child care
- Enhancing parent–child bonding, emotional ties, and communication
- Increasing access to social and health services for all family members
Interventions to address anger management and lack of self-control include the following:
- Anger control training aimed at recognizing “triggers” and reducing anger-arousing behaviors
- Relaxation training that seeks to short-circuit the aggressive behavior early in its development
- Communication skills training and problem-solving strategies
- Methods for aiding the parent or caregiver not only to reduce his or her own anger level but also to help his or her child do likewise
Other interventions commonly used for physical abuse cases include the following:
- Providing food, shelter, clothing, and/or utilities to stressed or impoverished families at the same time as counseling or parent education to reduce the anxiety or stress that may lead to future maltreatment
- Addressing factors underlying physical abuse, such as substance abuse and/or domestic violence; if an assessment identifies the presence of these issues, they should be addressed as an intervention strategy to lower the risk of future abuse
- For children, specifically discussing the child’s perception of the circumstances surrounding the abuse as well as the details of the abuse itself (depending on the child’s level of emotional and cognitive development, children often blame themselves; they need help identifying their shame and guilt and should be told they did not cause the abuse)
- Training children in self-expression, self-control, and effective problem-solving; interventions should teach children alternative ways to express their feelings and thoughts, especially anger and anxiety
All of the interventions used to address child physical abuse should link the underlying cause of abuse to the intervention’s purpose. No single intervention approach will be universally effective for all individuals.
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- S. Department of Health and Human Services, Administration on Children, Youth and Families, Children’s Bureau, Office on Child Abuse and Neglect. The Child Abuse and Prevention Treatment Act. Retrieved May 27, 2017, from https://www.acf.hhs.gov/sites/default/files/cb/capta_40yrs.pdf
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