Ryan Brown, MD, FAAP
Clinical Associate Professor, University of Oklahoma College of Medicine, Department of Pediatrics
Medical Director, Child Protection Team at The Children’s Hospital at OU Medical Center
Child maltreatment is a terrible fate that children may face. Unfortunately, no one is immune to the effects of abuse. Child maltreatment has been shown to affect children from all races, genders, ages, and socioeconomic background.1 Every year there are hundreds of thousands of children that fall victim to this atrocious calamity. During 2015, child protection services received over 4 million referrals for child maltreatment. Those referrals encompassed 7 million children of which about 700,000 were found to be victims of abuse. Unfortunately, the victimization rate has been increasing over the past 5 years from 8.8 to 9.2/100,000 children.2
In order to recognize abuse, one must first know how to define it. According to the Child Abuse Prevention and Treatment Act (CAPTA) that was reauthorized in 2010, child maltreatment is defined 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.” 3
Nationwide, neglect is the overwhelming cause of maltreatment. In 2015, three-quarters 75.3% of all child victims were determined to be neglected. This was followed by physical abuse at 17.2% and sexual abuse at 8.4%. 6.9% of child victims were listed as being victims of “other” forms of abuse such as exposure to parent drug and alcohol abuse and threatened harm.2 The total exceeds 100%. It is important to understand that being a victim of one type of abuse does not make a child immune to other forms. 86% of child victims suffered from a single type of maltreatment, whereas 14% had polyvictimization with neglect and physical abuse being the most common combination. 2 Therefore, if evaluating a child for one type of maltreatment, it is important to look for signs or symptoms of other forms of abuse.
The Emergency Department (ED) plays an important role in the evaluation and treatment of children who are maltreated. In the United States between 2006 to 2011 about 1.3% of ED visits were attributed to abuse in children 3 years of age or younger.4 It has been shown that one-third of child maltreatment victims (27.7%) are less than 3 years of age.2 Unlike the national percentage of maltreatment overall, in the ED physical abuse was the most common cause of abuse followed by neglect and sexual abuse.4
General knowledge of how abuse victims can present to the ED can be helpful. Overall, boys and girls are abused at the same rate.1 However, for ED visits for physical abuse, boys are more likely to be seen than girls (56% vs. 46%). 4 Interestingly, physical abuse in children seen in the ED occurred more often during the weekdays (75.6%) compared to weekends (23.4%). 4 Abused children have worse injuries and worse outcomes when compared to children who sustained injuries unintentionally. Abused victims were three times the number of intracranial injuries (42.2% vs. 14.1%), triple the rate of thoracic injury (12.5% vs. 4.5%), and double the rate of abdominal injuries (11.4% vs. 6.8%).6 It is important to point out here that abusive head trauma is the most common cause of death in child abuse cases.7 Also, victims of abuse had nearly double the rate of being admitted to the ICU due to injuries (42.5% vs. 26.9%) and more than double the length of stay in the hospital (9.3 days vs. 3.8 days).6
In closing, child maltreatment is a medical condition that should be on the radar of all medical personal in the ED. The signs and symptoms of abuse can mirror those of normal injury. The difference is history and intent.
- Kellogg ND (2007) American Academy of Pediatrics Committee on Child Abuse and Neglect. Evaluation of suspected child physical abuse. Pediatrics.119(6): 1232.
- U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2017). Child Maltreatment 2015. Available from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment
- (2010). CAPTA Reauthorization Act of 2010: Report (to accompany S. 3817). [Washington, D.C.: U.S. G.P.O.
- King, A. J., Farst, K. J., Jaeger, M. W., Onukwube, J. I., & Robbins, J. M. (2015). Maltreatment-Related Emergency Department Visits Among Children 0 to 3 Years Old in the United States. Child Maltreatment, 20(3), 151–161.
- Allareddy, Veerajalandhar, et al, Hospital Based Emergency Department Visits Attributed to Child Physical Abuse in United States: Predictors of In-Hospital Mortality. 2014: 9(6), e100110.
- DiScala C et al, Child Abuse and Unintentional Injuries: A 10 year retrospective, Arch Pediatr Med. 2000;154:16-22
- Alexander RC, Levitt CJ, Smith W (2001) Abusive head trauma. In: Reece RM, Ludwig S, eds. Child Abuse: Medical Management and Diagnosis. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins: 47–80.