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Child Maltreatment

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Overview

Child maltreatment (or child abuse) is the abuse of children under 18 years old. NICE have the following definitions regarding age:

  • Infants are <1 year old
  • Children are <13 years old
  • Young people are aged 13-17 years old

Child maltreatment includes any type of abuse or neglect of a child/young person due to inflicting harm or failing to act to prevent harm. Types of abuse include:

  • Neglect
  • Physical abuse
  • Sexual abuse
  • Emotional abuse
  • Fabricated/induced illness

All doctors have a duty to report concerns that a child may be at risk including doctors working with adult patients where they suspect the patient’s child may be at risk.

This chapter is a summary for exams and like all material on this site, is not a substitute for training and must not be used in clinical practice. Always discuss concerns with an experienced senior colleague.

Definitions

Consider and suspect

CONSIDER – child maltreatment is a possible differential diagnosis for the presentation

SUSPECT – the possibility of child maltreatment is high, but not definite

Types of abuse

Neglect describes the persistent failure to meet a child/young person’s basic physical/psychological needs that may impair their health/development seriously such as:

  • Not providing food/shelter
  • Inadequate protection from danger/emotional harm
  • Inadequate supervision and caregiving
  • Inadequate access to medical care/treatment
  • Emotional neglect

Physical abuse describes causing physical harm such as hitting, shaking, throwing, burning, poisoning, scalding, and suffocating. Physical harm may also be caused to fabricate/induce illness in a child/young person.

Sexual abuse involves forcing/coercing a child/young person to take part in sexual activities, regardless of whether violence was used and if the child/young person is aware of what is happening.

  • This includes penetrative, non-penetrative acts, and non-contact activities such as producing pornography, the child looking at sexual activities/pornography or encouraging inappropriate sexual behaviour in a child/young person.

Emotional abuse describes persistently treating a child/young person in a way that can cause negative effects on the child’s emotional development.

  • This can include making them worthless/unloved, setting unrealistic expectations, making fun of them, bullying, purposefully scaring them etc.

Fabricated/induced illness (factitious illness by proxy – formerly known as Münchhausen’s syndrome by proxy) describes when a child/young person is, or is likely to be, harmed to convince doctors that the child/young person’s physical/mental/neurodevelopmental health is impaired. This can cause neglect, physical, and emotional abuse, and can cause iatrogenic harm.

Child safeguarding

Child safeguarding is defined as:

  • Protecting children/young people from maltreatment
  • Protecting children/young people from experiences that could impair mental and physical health/development:
  • Ensuring children/young people are growing up in a safe environment with consistent, safe, and effective care
  • Taking action to ensure children/young people have the best outcomes

Epidemiology

The World Health Organisation (WHO) reports that:

  • Nearly 3 in 4 children 2-4 years old regularly suffer physical and/or psychological abuse from parents/carers
  • 1 in 5 women and 1 in 13 men report having been sexually abused as a child (0-17 years)

Child maltreatment is likely to be under-recognised and under-reported, and it is difficult to identify the prevalence of child maltreatment.

Risk Factors

Any child/young person is at risk of child maltreatment, regardless of the presence or absence of risk factors.

  • Child risk factors include:
    • <4 years old or adolescence
    • Excessive crying in infants:
    • Physical and/or mental impairment
    • Being unwanted/failing to fulfil expectations of parents/carers
    • Identifying or being identified as LGBTQ+
    • Living in the care system
    • Twin/multiple
  • Parent/carer risk factors include:
    • Drugs and crime:
      • Substance misuse
      • History of domestic abuse
      • History of criminal activity including violent crime
    • Regarding physical/mental health:
      • Emotional volatility or problems managing anger
      • Psychiatric/neurological disorders
      • Learning difficulties
    • Other factors:
      • Known maltreatment of animals
      • Poor education
      • Lack of parenting knowledge
      • Low self-esteem
      • Previously abused parent
      • Non-engagement with services
      • Poverty/financial pressures/poor housing
      • Family/relationship breakdown

Assessment

General principles

In all cases of suspected child maltreatment:

  • Listen and observe – history, signs/symptoms, physical exam findings, parent-child interaction, investigations, reports from third parties
  • Seek an explanation – ask non-judgementally and openly about all features:
    • There may be explanations inconsistent with the child’s age/development/history etc., or inconsistencies between parents/carers or the child
    • Cultural practices are not acceptable excuses for child maltreatment
  • Record what is said and observed including by whom and why you are concerned, including minor concerns, decisions and actions relating to concerns, and outcomes

Always ask about any other children who are at risk.

Communication

Some tips that may be helpful in OSCEs include:

  • Using open questions:
    • Children may be more inclined to give answers that they think may satisfy the clinician, particularly when scared or overwhelmed
  • Beingnon-judgemental:
    • The fear of being stigmatised, feeling shame, guilt, or confusion, are possible barriers to children opening up about maltreatment
  • Avoiding coming across as accusatory:
    • Difficult questions need to be asked and may offend parents, carers, or the child, which may make them defensive or lead to withholding information
    • Prefacing questions with something like, “We usually ask this to all patients with similar symptoms” before asking a difficult question is reassuring and non-accusatory 
  • Involving the child as much as possible:
    • This allows them to feel in control of what is going on, promotes forming a trusting relationship, and eliminates bias or missed points
  • As long as it is safe to, be open and transparent:
    • Where possible and if it is safe to, you should tell the parent/carer you are making a referral to social services. If the child is at immediate risk, an emergency protection order can be sought
    • As mentioned above, avoid being accusatory and explain why a referral is important, such as “With injuries similar to these, we cannot always tell if they are accidental or not, so we have to refer all cases” and “These rules are in place so that all children are safe and protected”

General Features

Overview

Some features that are associated with child maltreatment (alerting features) are:

  • Frequent or unusual patterns in attendance to healthcare services and frequent injury
  • Injuries that are inconsistent with the story or child’s age/development
  • Parents/carers refusing to let the child/ speak to a healthcare professional on their own
  • Unusual or marked changes in behaviour inconsistent with age/developmental
  • Poor school attendance with no appropriate explanation
  • Has responsibilities that interfere with essential normal daily activities (e.g. going to school)
  • Inappropriate/unusual sexual behaviour, pregnancy, or sexually transmitted infection
  • Evidence of neglect
  • Abandoning the child

Emotional and Behavioural Abuse

Child behaviour

Child maltreatment may be possible if a child’s behaviour is not consistent with their age/development or cannot be explained by another other cause such as:

  • Emotional – fear, withdrawn, poor self-esteem, extreme distress
  • Behaviour – aggression, opposition, body rocking
  • Interpersonal – clinginess, overfriendliness to strangers, ‘good behaviour’ to avoid upsetting parent/carers, showing excess comforting behaviours when a parent/carer is distressed
  • Dissociation – episodes of detachment (‘feeling like they’re outside their own body’)
  • Responds to health assessment/examination unusually or inappropriately

Behavioural disorders/abnormalities may be present which include:

  • Self-harm – such as cutting, scratching, picking, biting, pulling out hair
  • Eating and feeding behaviours – such as scavenging, stealing, hoarding, or hiding food
  • Wetting and soiling including:
    • Secondary day/nighttime enuresis (wetting) persisting despite adequate assessment with no underlying cause (e.g. urinary tract infection, bereavement)
    • Intentional wetting
    • Encopresis – defecating in inappropriate places or deliberately smearing faeces
    • Punishing a child when wetting or soiling despite being told it is involuntary
  • Sexualised behaviour
  • Runaway behaviour – if a child has run away from home or living somewhere else without the full agreement of parents/carers

Parent-child interactions

Some features of emotional abuse may include potentially harmful parent-child interactions:

  • Negativity, hostility, unresponsiveness, emotional unavailability towards the child
  • Expectations or interactions with the child that are developmentally inappropriate including inappropriate threats and disciplining
  • Using the child for the adult’s needs (e.g. marital disputes)
  • Isolation, not providing stimulation or education, involving the child in illegal activities
  • Refusing to allow the child to speak to a healthcare professional alone.

Physical Abuse

Overview

Suspect physical abuse if any of the following are present with an absent/unsuitable explanation:

  • Bruising or petechiae:
    • Factors relating to the child:
      • A child who is non-mobile or not independently mobile – very unusual to just ‘be clumsy and fall’
    • Shape and size:
      • In the shape of a hand, stick, ligature, teeth mark, grip, or implement
      • Multiple/clustered bruises
      • Bruises of similar size/shapes
    • Location:
      • On non-bony parts of the body or face (e.g. eyes, ears, abdomen, buttocks)
      • On the neck/wrists resembling ligature marks
      • On the neck resembling being strangled
  • Bites:
    • Human bite marks that are not likely to be due to a young child
    • Animal bite marks on a child who has been inadequately supervised
  • Lacerations, abrasions, or scars:
    • Factors relating to the child:
      • A child who is non-mobile or not independently mobile – very unusual to just ‘be clumsy and hurt themselves’
    • Location:
      • Over areas usually covered by clothing (e.g. back, chest, abdomen, axilla, groin)
      • On the eyes, ears, and sides of the face
      • On the neck, ankles, or wrists resembling ligature marks
    • Distribution:
      • Multiple lacerations, especially if symmetrical
  • Burns/scalds:
    • Factors relating to the child:
      • A child who is non-mobile or not independently mobile – very unusual to just ‘be clumsy and hurt themselves’
    • Location:
      • On an area not that is not usually in contact with a hot item by accident (e.g. backs of hands, soles, buttocks, back)
    • Shape and distribution:
      • In the shape of a tool or implement (e.g. iron or cigarette)
      • Suggesting immersion such as a to the buttocks to the lower limb, symmetrical distribution, glove or stocking distribution, scalds with sharp margins
  • Fractures:
    • Factors relating to the child:
      • A child who is non-mobile or not independently mobile – very unusual to just ‘be clumsy and hurt themselves’
    • Number and age:
      • One or more fractures without a predisposing condition
      • Fractures of different ages/stages of healing
      • X-ray evidence of occult fractures (e.g. rib fractures in infants)
  • Head injury – no accidental trauma or medical cause and:
    • <3 years old
    • Associated retinal haemorrhages, rib/long bone fractures, and other injuries
    • Multiple subdural haemorrhages with/without subarachnoid haemorrhage with or without brain hypoxic-ischaemic damage
  • Poisoning:
    • Factors relating to the child:
      • The child is unable to access the substance on their own
      • Repeated ingestions in the child/other children at home
    • Factors relating to the substance:
      • Deliberate administration of inappropriate substances (e.g. drugs, chemicals, salt)
      • Unexpected blood levels of drugs not prescribed for the child
      • Reported/biochemical evidence of ingestion of toxic substances
  • Repeated apparent life-threatening events (ALTEs)/brief unresolved unexplained events (BRUE)
    • An ALTE is a descriptive term that is frightening to the observer such as apnoea, colour changes, changes in muscle tone, gagging, or choking.
  • Intra-abdominal/intrathoracic injuries without accidental trauma
  • Eye trauma without accidental trauma – retinal haemorrhages
  • Spinal injuries without confirmed accidental trauma
  • Submersion injury/drowning with an inadequate explanation or in an unsupervised child

Consider physical abuse if any of the following are present without an adequate explanation:

  • Cold injury (e.g. swollen, red hands or feet)
  • Hypothermia
  • Oral injuries
  • Serious or unusual injuries
  • Hypernatraemia – may suggest denial of water or poisoning with salt
  • Unusual patterns of presentation and healthcare providers or frequent presentations/reports of injury

Sexual Abuse

Overview

In general:

  • Sexual activity between adults and children <16 years old is illegal
  • A child <13 years old cannot legally consent to any sexual activity
  • It is illegal for a person in a position of trust to engage in sexual activity with a child <18 years old or a person with learning difficulties or psychiatric illness
  • Sexual activity between two young teenagers <16 years old (but neither are <13) is illegal, although it is unlikely to lead to prosecution if mutually agreed and there is no abuse or exploitation

Anogenital signs and symptoms

Suspect sexual abuse if any of the following apply with an absent/unsuitable explanation (e.g. constipation, Crohn’s disease):

  • Genital, anal, or perianal injury – such as bruising, laceration, swelling, abrasion
  • Persistent/recurrent anogenital symptoms associated with behavioural/emotional changes – such as bleeding or discharge

Consider sexual abuse if any of the following apply with an absent/unsuitable explanation:

  • Anal dilation during an examination
  • Anogenital symptoms – such as bleeding or discharge
  • Persistent/recurrent dysuria or anogenital discomfort – such as worms, UTI, skin infections, poor hygiene
  • Evidence of one or more foreign bodies in the vagina or anus

Sexually transmitted infections (STIs)

For children <13 years old:

  • Suspect sexual abuse if a child <13 years old has:
    • STIs (such as gonorrhoea, Chlamydia, genital herpes, hepatitis C, HIV, or trichomoniasis) with no evidence of vertical transmission
  • Consider sexual abuse if a child <13 years old has:
    • Hepatitis B or anogenital warts with no clear evidence of vertical transmission or non-sexual transmission

For people <13-15 years old, consider sexual abuse if any of the following apply:

  • Hepatitis B, anogenital warts, or STIs with no clear evidence of vertical transmission, non-sexual transmission, or consensual sexual activity with a peer

For people 16-17 years old, consider sexual abuse if the following apply:

  • Hepatitis B, anogenital warts, or STIs and there are:
    • No evidence of vertical transmission, non-sexual transmission, or acquired from consensual sexual activity with a peer
    • A clear difference in power/mental capacity is present (e.g. incestuous, teachers, religious ministers, sports coaches)
    • Concerns that the person is being exploited

Pregnancy

Children <13 years old cannot consent to any sexual activity, therefore, pregnancy means the child has been sexually abused.

Consider sexual abuse if:

  • A person aged 13-15 is pregnant
  • A person aged 16-17 is pregnant and there are:
    • A clear difference in power/mental capacity is present (e.g. incestuous, teachers, religious ministers, sports coaches)
    • Concerns that the person is being exploited
    • Concerns that the sexual activity was non-consensual

Neglect

Overview

Suspect neglect if:

  • The child is persistently dirty/smelly
  • There are reports of any of the following:
    • Poor standard of hygiene
    • Inadequate food provision
    • An unsafe environment for the child’s developmental age
  • Parents/carers fail to seek medical advice to the point where the wellbeing of the child is compromised, including if they are in pain

Consider neglect if:

  • Hygiene, clothing, diet, and environment:
    • Severe/persistent infections – such as scabies/head lice
    • Inappropriate clothing/footwear – such as inappropriate for weather/child’s size
    • Faltering growth due to inadequate diet/lack of provision
    • Not being cared for by someone who can provide adequate care
    • An injury (e.g. ingesting a harmful substance or sunburn) suggests a lack of appropriate supervision
  • Parent/carer behaviour:
    • Fails to give prescribed treatment to the child
    • Repeatedly misses follow-up appointments for the child
    • Persistently does not engage with child health promotion programmes (e.g. immunisation, health and development reviews, screening)
    • Has access to, but persistently does not obtain treatment for tooth decay
    • Fails to seek medical advice to the point where the wellbeing of the child is compromised, including if they are in pain

Fabricated/Induced Illness

Suspect fabricated/induced illness if the child’s history, presentation, examination, or test results do not match a recognised clinical picture and any of the following are present:

  • Regarding symptoms:
    • Symptoms that only appear/reappear when the parent/carer is present
    • Symptoms that are only seen by the parent/carer
    • New symptoms reported as soon as old ones have resolved
  • Regarding the history:
    • A history of clinically unlikely events (e.g. claiming the child has lost a lot of blood but has not become unwell/anaemic)
  • Regarding seeking opinions despite a clinical opinion being reached:
    • Despite a clinical explanation being reached, multiple opinions from primary and secondary care are sought and disputed by the parent/carer and the child continues to be presented for tests and treatment
  • Regarding the direct impact on the child:
    • Normal daily activities are being compromised (e.g. going to school)
    • Using aids (e.g. wheelchairs) more than would be expected for the condition they have
    • Inappropriate substances including drugs may have been used to induce illness – this links to physical abuse

Management

Overview

All NHS care organisations have a safeguarding team or designated safeguarding lead to help with safeguarding concerns. In all cases, escalate to a senior if maltreatment is suspected.

Child maltreatment cases are generally referred to social services (children’s services) who investigate further, involve relevant parties, and decide the next steps.

If the child is in immediate danger, the police may need to be involved or if they are acutely unwell, they may need to be admitted to hospital.

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