brand logo

Am Fam Physician. 2022;105(5):521-528

Author disclosure: No relevant financial relationships.

Child maltreatment is a devastating type of adverse childhood experience that encompasses neglect and emotional, physical, and sexual abuse (including sex trafficking). Adverse childhood experiences are exposures to maltreatment or household dysfunction during crucial developmental periods that disrupt neurodevelopment and can result in lifelong physical and psychological harm, altering the child's behavior and disease risk into adulthood. Maltreatment can affect patients of any gender identity and from all racial and ethnic backgrounds, socioeconomic statuses, and community settings. Use of the validated five-item Pediatric Hurt-Insult-Threaten-Scream-Sex screening tool to identify victims of child abuse is recommended. All suspected cases of child abuse must be reported to Child Protective Services. A trauma-informed approach to care requires that team members be mindful of the potential for traumatic stress, recognize and appropriately respond to the symptoms and signs of trauma, and prevent retraumatization. Prevention through education and anticipatory guidance provided during routine well-child visits and community partnerships can foster awareness and resiliency in children. Although caring for victims of child maltreatment may be among the most challenging professional situations encountered by physicians, advocating for these endangered patients can save lives and help prevent revictimization and chronic sequelae associated with adverse childhood experiences.

The U.S. Department of Health and Human Services defines child maltreatment as “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.”1 Child maltreatment is a type of adverse childhood experience. These involve exposures to maltreatment or household dysfunction during crucial developmental periods that can have profound impacts on physical, neurologic, and intellectual development (Table 1).24 These impacts may then result in negative and enduring effects on health and behavior in a compounding manner.5 Risk factors and protective elements for victimization and perpetration of child maltreatment can be framed in terms of the child, the caregiver or abuser, and the environment (Table 2).1,6

Health-risk behaviorsHigh-risk sexual behaviors, revictimization, sexually transmitted infections, substance abuse, suicidal ideations or attempts, unplanned pregnancies
Medical conditionsFibromyalgia, irritable bowel syndrome, obesity
Psychological conditionsAnxiety, depression, posttraumatic stress disorder
SourceRisk factorsProtective factors
ChildChronic illness
Emotional or behavioral difficulties
Physical disabilities
Preterm birth
Unplanned or unwanted pregnancy
Above average cognitive ability
Belief in one's ability to control own destiny
External attribution of blame
High degree of impulse control and modulation
High self-esteem or sense of self-worth
Presence of spirituality
Caregiver(s)Alcohol or other substance abuse
Criminal history
Depression or other mental illness
Development of unrealistic expectations for the child
History of abuse
Low educational attainment
Low self-esteem
Negative perception of normal childhood behavior
Poor impulse control
Poor knowledge of the child
Young parental age
Caregiver resilience
Caregiver social support network
Home environmentFamily or intimate partner violence
Non–biologically related adult living in the home
Single-parent home
Presence of caring and supportive adult
Community environmentPoverty
Social isolation or lack of social support
Access to good health, education, and social welfare services
Caring adult in school or extracurricular activities
Involvement with extracurricular activities or hobbies
Involvement with religious community
Structured school environment

Maltreatment can affect patients of any gender identity and from all racial and ethnic backgrounds, socioeconomic statuses, and community settings. The actual number of maltreated children is challenging to track because of a lack of consistent reporting and difficulty confirming suspicions. The prevalence of maltreatment varies by type, gender, and geographic location.7 Approximately 4.4 million children are reported to Child Protective Services (CPS) each year, and about nine out of 1,000 children in the United States have evidence of maltreatment after investigation.8

Being vigilant for possible child maltreatment, knowing how to assess for and report it, and remaining adept at providing a trauma-informed approach to care9,10 (Table 33,1113) within a multidisciplinary team can help optimize patient care. The principles of trauma-informed care require the health care team to realize the widespread impact of trauma, recognize and appropriately respond to signs and symptoms of trauma, and actively prevent retraumatization in their patients.14

Preview chart, if available, for documentation regarding trauma to prevent revictimization by asking the patient to completely repeat this history
Remain seated to prevent the perception of a patient-physician power differential
Discuss the importance of confidentiality, trust, safety, and holistic care and expectations for the encounter (i.e., history with detailed note taking, comprehensive physical examination, and procedures, laboratory testing, imaging, and referrals as clinically indicated)
Ask open-ended questions in a nonjudgmental manner and explain medical rationale for asking sensitive questions (e.g., sexual and substance use histories)
If using an interpreter, inquire about cultural and gender preferences
Key history components
Developmental, medical, surgical, social, and family histories (especially with relation to genetic, metabolic, hematologic, and bone disorders)
Familial disciplinary methods, the child's baseline temperament and demeanor, and biopsychosocial stressors affecting the family
History of child, sibling, and parental/caregiver trauma
History of parental/caregiver substance abuse, incarcerations, arrests, intimate partner violence, behavioral health conditions, and previous or current Child Protective Services or law enforcement involvement with the patient's family
Maternal pregnancy and behavioral health histories
Physical examination
Consider referral to a medical forensic professional or child abuse team before performing an examination
Ensure presence of a chaperone
Ask the child if they are anxious about any components of the examination, and if there is anything that you can do to improve their comfort
Discuss that they can dictate the pace of the examination
Provide children with gowns and drapes for the examination
Judiciously expose and cover bodily areas (ask the patient to do so, if able, to promote personal empowerment) during examination to maximize privacy
Use age-appropriate language and ask permission to proceed with increasingly sensitive portions of the examination
Offer suggestions about how to potentially improve patient comfort while the examination is being performed (e.g., it may be helpful to take a deep breath during this portion of the examination)
Verbalize what is intended to be visualized and why
Discuss any invasive procedures (e.g., speculum examinations) in detail, obtain consent, and describe to the patient what they might experience (e.g., hearing a click with speculum opening)
Avoid performing repetitive anogenital examinations as able to prevent retraumatization

Types of Abuse

All suspected cases of child abuse must be reported to CPS.1,9,10 Major categories of abuse include neglect, and emotional, physical, and sexual abuse.


Neglect consists of parental omissions in care that result in actual or potential harm to a child.1,15 It is the most common form of child maltreatment, occurring as the only offense in 61% of all cases of confirmed maltreatment and in combination with abuse in 15% of cases.16 Additionally, it accounts for 73% of child fatalities caused by maltreatment.16

Neglect occurs when a child's basic physical, emotional, educational, or medical needs are not adequately met in a consistent pattern.1,15 Physical neglect involves exposure to environmental hazards that could lead to injuries or harmful ingestions, or a failure to provide adequate hygiene, nutrition, clothing, or shelter.1,15,17 Inadequate supervision is a subtype of physical neglect that includes abandonment and expulsion.1,15,17 Medical neglect results from refusing or delaying necessary health care.1,9,15,17 Emotional neglect involves inadequate nurturing or affection, an exposure to intimate partner violence, permitted drug or alcohol abuse, or refusing or delaying necessary psychological care.1,15,17 Educational neglect includes a failure to enroll a child in school, truancy, or inattention to special education needs.15,17

Manifestations of the subtypes of neglect overlap and can include malnourishment or failure to thrive, advanced medical or dental disease, developmental delays, attention-deficit/hyperactivity disorder, and alcohol or drug abuse, all of which can cause long-term intellectual, social, and psychological deficits.15,17,18 Assessment of suspected neglect involves taking a detailed medical and psychosocial history (i.e., growth, immunization status, previous hospitalizations, family stressors, and past contact with CPS) and performing a thorough physical examination.15 Additional guidance is provided in Table 33,1113 and Table 4.11,19 Evaluations should also include screening for contributing factors (e.g., poverty, food insecurity, lack of transportation, lack of health care access, language barriers, low health literacy). Screening tools are listed in eTable A. Referral to appropriate community resources is warranted when concerns are identified.9,15,18 Home visitation programs have been shown to reduce the incidence of maltreatment in high-risk families.2022 CPS referrals are indicated when assistance has been offered and refused, and the child's needs have been left unmet.15

InjuryDifferential diagnoses
Bite marks
Abrasions, lacerations, or ecchymoses in an ovoid or elliptical pattern
May require co-evaluation by dentist or forensic odontologist
Accidental or nonaccidental bite mark from animal or another human
Age cannot be accurately determined forensically
External sign of potentially severe internal injury
Inflicted bruises may occur in atypical locations (e.g., behind ears, inside lips, along hard palate of mouth)
Noninflicted bruises are usually notable on shins, knees, and forehead
Accidental or nonaccidental trauma, dermatologic disorders, congenital dermal melanocytosis, Henoch-Schönlein purpura, genetic disorders (e.g., Ehlers-Danlos syndrome), vascular or hematologic disorders
Object contact burns
Scalding immersion burns
Accidental or nonaccidental burn, dermatitis, skin infection, Stevens-Johnson syndrome, toxic epidermal necrolysis
Commonly identified on skeletal radiographs
Improved detection with repeated imaging
Accidental or nonaccidental fracture, birth trauma, congenital syphilis, leukemia, osteogenesis imperfecta, osteomyelitis, physiologic changes, vitamin deficiencies
Head trauma
Associated with abuse-related fatalities
Recommend co-assessment by ophthalmologist
Accidental or nonaccidental trauma, birth trauma, hemorrhagic disease, infection, intracranial vascular anomalies, metabolic disease
Educational websites and screening tools
Child Welfare Information Gateway: Child Abuse and Neglect
National Child Traumatic Stress Network
Screening tools for adverse childhood experiences
Tools for assessing social determinants of health and patient resources
The EveryONE Project
Clinical resources
Evaluation of Suspected Child Physical Abuse
Trauma-informed care
Suspicious injuries concerning for nonaccidental trauma or physical injury
Sexual abuse and trafficking
National Human Trafficking Hotline
Normal and abnormal sexual behaviors in children
Evaluating the Child for Sexual Abuse
Common Health Issues Seen in Victims of Human Trafficking
Child abuse prevention programs
The Pediatrician's Role in Child Maltreatment Prevention
Reporting and documentation
Hotlines and telephone numbers for reporting suspected abuse:
(1) National Sexual Assault Hotline: 1-800-656-HOPE (4673)
(2) Childhelp National Child Abuse Hotline: 1-800-4A-CHILD (422-4453)
(3) National Human Trafficking Hotline: 1-888-373-7888
(4) National Teen Dating Abuse Helpline: 1-866-331-9474
(5) National Suicide Prevention Lifeline: 1-800-273-8255
Listing of state child abuse and neglect reporting numbers
How to Report Child Abuse and Neglect
An Advocate's Guide to Mandatory Reporting
Forensic photography
Tips for clinicians preparing to testify in court


The Child Abuse Prevention and Treatment Act defines psychological maltreatment as repeated patterns of caregiver behavior or extreme incidents that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs.4,23 Also known as emotional abuse, this subtype may be widely prevalent but is difficult to detect because of a lack of physical findings and difficulty discerning when suboptimal parenting becomes maltreatment.24 Even though emotional abuse is generally present when other forms of abuse are identified, only 8% of victims substantiated by CPS are confirmed to have experienced emotional abuse in isolation.1 Harmful parental behaviors are varied and include spurning, terrorizing, rejecting, isolating, exploiting, corrupting, denying emotional responsiveness, demonstrating unreliability or inconsistency, verbally assaulting, overpressuring, and neglecting emotional needs.4,23,24

Indicators that may warrant an evaluation include attention problems, violent or oppositional behaviors, difficulty with attachment or impaired social skills, developmental or educational delays, depression, anxiety, or physical manifestations (e.g., psychosocial short stature or failure to thrive).1,4,24,25 During the assessment, it is important to include specific quotes from both parent and child to document observations and substantiate claims.4,24 Reports from a child's school, childcare workers, or other professionals involved with the family can help guide management.4

The response to emotional abuse depends on both intent and harm, and options include parental education, counseling, CPS referral, and potentially removing the child from their home.23 Trauma-specific psychotherapy with an emphasis on cognitive behavior therapy or other behavioral therapies can provide benefit; psychopharmacologic intervention as a temporary adjunct may be useful to modulate specific symptoms such as difficulty sleeping, nightmares, and anxiety.1,25,26 Although the U.S. Preventive Services Task Force found insufficient evidence to balance the benefits and harms of primary care interventions, the American Academy of Family Physicians still endorses the provision of developmentally appropriate anticipatory guidance and preventive education, and instructions on healthy parenting approaches during well-child visits.27,28 Participation in parenting training programs (e.g., Triple-P: Positive Parenting Program) and educational home visitation programs (e.g., Nurse-Family Partnership) may be indicated when risk factors are present (Table 2).1,6


Physical abuse encompasses any nonaccidental physical injury (e.g., biting, striking, burning, kicking) or action that results in the physical impairment of a minor.1 The most common types of injuries include bruises, burns, bite marks, fractures, and head trauma1; further details are available in Table 411,19 and eTable A. When a child presents with an injury, the potential for nonaccidental trauma should always remain in the differential diagnosis, because earlier detection of nonaccidental trauma can reduce morbidity and mortality.12 Using the validated five-item Pediatric Hurt-Insult-Threaten-Scream-Sex screening tool to identify victims of child abuse and taking a trauma-informed approach to care are recommended.3,29,30 The Pediatric Hurt-Insult-Threaten-Scream-Sex questionnaire assesses on a scale from 0 to 5 how often an immediate family member was estimated to have physically hurt, insulted, threatened, screamed or cursed at, or forced sexual acts on a child 12 years or younger within the past year; higher scores indicate an increased exposure to abuse.29

After ensuring that the child is hemodynamically stable, the clinician should obtain a comprehensive history from the patient (if able, based on language capabilities) and caregivers, preferably separately, using a nonaccusatory and sensitive manner with a focus on open-ended questions to create a safe environment and develop a trusting rapport. It is important to note details about the timing and mechanism of injury, symptom onset and progression, the child's behavior at baseline, any changes in behavior during and after the injury, and the child's demeanor both with and without the caregiver present. Vague and inconsistent explanations, denials of injury, and excessive delays in obtaining medical care may indicate abuse.11,12 Additional useful information to obtain during this trauma-informed assessment is included in Table 3.3,1113

In all children presenting with injuries, physical examination findings should be evaluated carefully in the context of their developmental levels, mechanisms of injury, histories, and laboratory and imaging findings. Isolated injuries are rarely pathognomonic for child abuse. Resources that can help clinicians identify suspicious injuries are included in eTable A. Injuries should be distinguished as either noninflicted/unintentional or inflicted/intentional. Inflicted injuries can be further classified as sentinel injuries (i.e., minor injuries that are detected before the recognition of child abuse) and defensive injuries (i.e., those sustained in self-defense, such as on the forearms). Signs of potential abuse include injuries that are unexplained, patterned, involving more than one organ system, in various stages of healing, in an atypical location (e.g., on the ears, neck, and face), or involving a preambulatory infant.11,12

Imaging and laboratory studies are typically indicated to further investigate physical examination findings (Table 511,12,31). Per guidelines from the American Academy of Pediatrics and American College of Radiology, a skeletal survey should be performed in all children with suspected physical abuse, especially those two years or younger.11,12,31,32 Comprehensive and detailed documentation is essential, and the inclusion of body diagrams and confidential forensic photographs may be useful to supplement the medical record, especially if requested to provide a court testimony or if records undergo a peer review13 (eTable A). Additionally, it is important to maintain a chain of custody with law enforcement or CPS that chronologically records the movement of medical documentation and other evidence from the assessment. Elements that have potential evidentiary value include sterile swabs and items of clothing containing biologic materials (e.g., saliva, blood, semen).

Funduscopic examinationRetinal hemorrhages (in children younger than two years)
Imaging studies
Abdominal CT scan with contrast mediaIntra-abdominal injuries
Bone scanOccult fractures (up to two weeks after injury)
Chest CT scan with contrast mediaIntrathoracic injuries
Head CT scan without contrast mediaSubarachnoid, subdural, or intraparenchymal injury
Skeletal survey radiographyOld or new fractures in all children, particularly those two years or younger, with suspected physical abuse
Laboratory testing
Amylase and lipase, coagulation panel (international normalized ratio, prothrombin time, and partial thromboplastin time), complete blood count, complete metabolic panel, fecal occult blood test, urinalysis, urine drug screenGenitourinary or intra-abdominal trauma, bleeding and coagulation disorders, metabolic dyscrasias


Sexual abuse represents a significantly underreported public health crisis that is associated with an array of potentially lifelong biopsychosocial manifestations. According to the Centers for Disease Control and Prevention, an estimated one in four girls and one in 13 boys are sexually abused during childhood, and the perpetrators are known by the child or the child's family in about 90% of cases.33 Additionally, sex trafficking of minors is an underestimated form of child sexual abuse that can involve the recruitment, provision, transportation, harboring, and solicitation of persons younger than 18 years in exchange for commercial sex acts. Victims may be children of all ages, races and ethnicities, gender identities, and socioeconomic backgrounds within rural, suburban, and urban communities in the United States and abroad.34 Table 6 lists psychosocial warning signs and physical features to look for in victims or their traffickers during an office visit.35,36

Psychosocial warning signsPhysical warning signs
Claim that the patient is “just visiting the area”
Display of emotional distress (e.g., depression, anxiety, low self-esteem)
Dominating or controlling adult in room with patient
Family dysfunction, abuse in the home, neglect or absence of a caregiver
Involvement with several sex partners
Lack of identification (e.g., driver's license)
Multiple foster home or group home placements
Prior record of arrest for prostitution
Relationship with an older adult
Repeated attempts to run away from home
Restricted or controlled communication
Sex industry association
Use of slang relating to street work
Victim in crisis, but downplaying health problems or risks
Victim resisting help because of fear
Atypical behavior (e.g., caused by traumatic brain injury)
Branding (e.g., tattoos with a name or initials)
Discrepancy between apparent and reported age (e.g., clues in behavior and appearance)
Inappropriate dress
Injuries around the head or mouth
Multiple visits for sexually transmitted infections
Presence of unexplained scars, scar tissue, or bruises
Signs of drug use, substance abuse, or intoxication
Signs of having intercourse while masking menses (e.g., retained cotton balls, tampons, and makeup sponges in the vaginal canal)
Signs of malnourishment
Signs of self-inflicted injuries or suicide attempts
Signs of sexual trauma
Vaginal wall thinning or tearing

Once the potential for child sexual abuse or sex trafficking is suspected, a physician's priorities comprise the following: (1) a safety assessment of the child's home environment (i.e., inquiring if the child is safe to return home, at risk of sustaining additional maltreatment in response to disclosing abuse, or at risk of being reexposed to a suspect at home), (2) the physician's professional duty to report suspected cases of abuse to appropriate government agencies, (3) a comprehensive evaluation of the child's mental and physical health, and (4) the possible need for a medical forensic examination (especially if patients present within 72 hours of an act of sexual abuse to obtain biologic specimens that could potentially have evidentiary value via rape/sexual assault kits) by referral to trained medical forensic professionals or transfer to a higher level of care (e.g., an emergency department, a child advocacy center, an abuse assessment clinic).11,13

When assessing children who may have been sexually abused, it is important to differentiate between normal and abnormal sexual behaviors. eTable A provides examples of ways to distinguish these behaviors in children up to 12 years of age. Many sexual behaviors that are considered normal increase in frequency and variety up until five years of age and wane afterwards.37 Notably, children with developmental delays may have different expectations of normal and abnormal sexual behaviors.

The aforementioned principles of assessing victims of physical abuse in a trauma-informed manner also apply to victims of sexual abuse. For female victims of sexual assault, a speculum examination is recommended in pubertal and postpubertal girls, but it is usually contraindicated in prepubertal children. For male and female victims, digital rectal and anoscopic examinations usually are not indicated. Sexually abused children with abnormal physical examination results should be further evaluated by clinicians with specialized training and experience.13,38 Medical examinations and records from all victims of sexual trauma should, ideally, be further reviewed by an experienced physician with medical forensic–related training.13,19,38

Of note, many victims of sexual abuse have anogenital examinations that appear normal, and a negative examination cannot disprove the occurrence of sexual trauma. These patients should be screened for sexually transmitted infections (i.e., HIV, syphilis, gonorrhea, chlamydia, and trichomoniasis). They can also be tested for bacterial vaginosis and vaginal candidiasis. Patients should receive treatment for any detected sexually transmitted infections and be offered emergency contraception and HIV postexposure prophylaxis.13,38

Once the occurrence of childhood sexual trauma is divulged, it can trigger distressing and emotionally charged responses throughout the child's support system. Physicians should remain vigilant for these responses and provide caregivers with anticipatory guidance, education, and resources for behavioral health services (especially those that specialize in childhood trauma) and child advocacy facilities. Parents are encouraged to support and believe their children, respond in a protective and calm manner, reassure their children that they are not at fault, and ensure close follow-up with their children's medical and behavioral health professionals.11,13

Although the various types of child maltreatment may have nuances in their presentations, there are similarities in many aspects of diagnosis and treatment. Physicians should use a trauma-informed approach and employ their duty to report all suspected cases of maltreatment, and the patient's medical care team should stay actively involved by facilitating access to behavioral health services and community resources.1,9,39 Strategies for preventing and managing all types of abuse and neglect, as well as helpful resources, can be found in eTable A and eTable B.

Cognitive behavior therapy–based parenting programs or referral to mental resources
Frequent follow-up
Legal notification
Referral to resources if financial or other stressors identified
Developmentally appropriate anticipatory guidance
Encouraging healthy parenting approaches, including appropriate disciplinary practices
Nurse-Family Partnership and other home visitation or school and community programs

This article updates a previous article on this topic by McDonald.12

Data Sources: A PubMed search was completed in Clinical Queries using the key terms “child abuse,” “physical abuse,” “physical trauma,” “sexual abuse,” “sexual trauma,” and “sex trafficking.” Search dates: February 20 and March 23, 2021. Essential Evidence Plus was also used with the search terms “child abuse” and “neglect.” Search dates: March 22, 2021, and January 7, 2022.

Continue Reading

More in AFP

More in PubMed

Copyright © 2022 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.