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

This clinical content conforms to AAFP criteria for CME.

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

EffectsExamples*
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

General
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

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

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