Peds, part 3: Principles - Types and Signs of Abuse and Neglect
by Meris Shuwarger BSN, RN, CEN, TCRN December 15, 2021 Updated: June 16, 2022 13 min read
In this article, we discuss types of child abuse, reporting requirements, and the signs of that abuse.
This subject matter may be difficult for some people; if you find this material discomfiting, please feel free to move on to our next video.
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
Types of Abuse
There are four major types of abuse as it relates to children:
Physical abuse: the intentional use of physical force against a child. This could be hitting, kicking, shaking, burning, or anything that could cause physical harm to a child.
Emotional abuse: behaviors that could harm a child's sense of self-worth, self-esteem, or emotional well-being. These include name-calling, shaming, or rejection.
Sexual abuse: forcing a child to engage in sexual acts such as fondling or penetration.
Neglect: the failure to meet a child's basic physical needs, for example, providing housing or food, education, or access to medical care. All are forms of neglect.
We’ll discuss each of these in more detail below.
Signs of abuse
These are the general signs of abuse to keep in mind.
Incompatibility between the story and the injury
If there is an inconsistency between the story of how an injury happened, and the injury itself, then that is suspect for abuse. For example, if a parent says, “My three-month-old crawled over to the stairs and fell down the stairs,” that is highly unlikely because a three-month-old would not have reached the crawling stage yet. Infants usually begin to crawl between 8-10 months.
Inconsistent story between the child and the caregiver
Related to this is an inconsistent story between the child and the caregiver. If the caregiver says one thing, but the child says another, even if neither one of them is saying anything about abuse, the inconsistency in the stories is a red flag that an injury could have resulted from abuse.
Injuries that are extremely unlikely given the child’s development
An example of this is a two-month-old who, according to the caregiver, “Crawled off the bed and hit his head.” A two-month-old is not able to crawl yet, making this set of events unlikely. And while it is possible for a two-month old to fall off a bed, the idea the child is crawling is unusual. Similarly, a child with burn injuries, for example, a four-month old, who “must have turned the bathwater on and fallen in” is another unlikely set of circumstances because it does not comport with the child’s developmental age.
Injuries that should have been avoided with basic parental supervision
As noted in the previous article, proper supervision is paramount to keeping children safe. From correct use of car seats to locking away poisons or locking access to swimming pools, most childhood injuries can be prevented with basic parental or caregiver supervision.
Remember that risk factors are based on the aggregation of data. This does not mean that somebody with these specific risk factors is going to abuse a child. It just means that a particular risk factor has been shown, through data, to be linked to something that might relate to abuse or abusive behavior.
Risk factors for abuse include children who are less than four years old or who have special needs, for example, if they have illnesses or disabilities. Consider that these children are the most demanding — an infant cries frequently, and a child who has an illness or disability needs extra attention.
A family history of mental health issues or substance abuse can put a child at risk for abuse.
Inconsistent, transient, or non-biological caregivers are also risk factors, as these people might not feel as committed to the children in their care as the children’s family members do.
Another risk factor is parents with low income or education levels, teenage parents, single parents, and parents who have many other young children.
Nurses are required to report suspicion of abuse. And, crucially, just because you report it, you do not have to provide proof. What is referred to as the “burden of proof” is not the nurse’s responsibility.
What is important to know is that nurses are mandated reporters. Mandated reporters are required to report suspicion of abuse. You do not have to provide proof, you just have to provide the facts and circumstances that lead you to suspect abuse. The documentation that you do can be of assistance to the patient for legal purposes.
To learn more about mandatory reporting, check out our Fundamentals of Nursing Flashcards.
Signs of abuse and neglect
Below we go into more detail about physical abuse, emotional abuse, sexual abuse, and neglect.
Physical abuse is the intentional use of physical force. This could be hitting, kicking, shaking, burning, or anything that could cause physical harm.
Signs of physical abuse
One sign of abuse is multiple injuries — for example, multiple fractures or many bruises that are in various stages of healing.
Another possible sign of abuse is bruises on the cheek, neck, genitals, buttocks, or back.
Remember that children get a lot of bruises when they're small, accidental bruises over their bony provinces, such as the knees or elbows or shins. That’s because they are running around, climbing, falling down, bumping into objects, etc. But these sorts of injuries do not usually occur in soft tissue areas. So a child with bruises on non-bony parts of their body may have been abused.
Bruises in the shape of a causative object, such as a belt, are another sign of possible abuse.
Similarly, burns in the clear shape of an object could indicate abuse. For example, a burn in the shape of an iron or a cigarette burn. Also, what are known as immersion burns. So if someone puts a child in hot water intentionally (to cause pain) and it results in a burn, we would see those immersion burns — often with a clear line of demarcation, where the burn begins or ends, for example, a child who has had their hand dipped in something scalding.
Another sign of abuse is spiral fractures. Spiral fractures occur when a long bone (e.g., the femur or humerus) is broken by a twisting force. The accidental causes of these are usually injuries from skiing, snowboarding, soccer, football, wrestling, or motorcycle accidents. A spiral fracture in a small child or infant is unlikely to be from these and can be a sign of abuse, for example, if the arm or leg was forcibly twisted.
Signs of shaken baby syndrome
The signs and symptoms of shaken baby syndrome include poor feeding, irritability, lethargy, vomiting, seizures, periods of apnea, and retinal hemorrhage (abnormal bleeding within the delicate blood vessels of the retina).
Shaken baby syndrome is a serious form of abuse inflicted on a child, usually occurring when a parent or other caregiver shakes a baby out of anger or frustration. Babies have weak neck muscles, which is why, when you hold them, you support their head. Shaking would cause the baby’s head to move dangerously back and forth, which could cause brain injury and head trauma.
Emotional abuse includes behaviors that could harm a child's sense of self-worth, self-esteem, or emotional well-being.
Signs of emotional abuse
The signs of emotional abuse may include a child who displays extreme behavior — they’re overly compliant or they are very demanding. Extreme passivity or aggression are other displays of extreme behavior.
Another sign of emotional abuse is delayed physical or emotional development. A child whose emotional needs are not being met may not be developing emotionally the way we would anticipate.
Sexual abuse: forcing a child to engage in sexual acts.
Signs of sexual abuse
The signs of sexual abuse include difficulty walking or sitting — a red flag for sexual abuse.
If a child exhibits advanced understanding or behavior sexually for their age — for example if a young child describes a specific sexual behavior or is seen demonstrating or attempting to demonstrate that behavior, especially with other children — that should be a red flag as well.
Other signs of sexual abuse include if a child has a sexually transmitted infection, an obvious sign of abusive contact. Additionally, a child with frequent urinary tract infections, especially in children with a vulva, may be experiencing abuse.
A new onset nocturnal enuresis (wetting the bed at night) could be a possible sign of sexual abuse.
Neglect is the failure to meet a child's basic physical needs.
Signs of neglect
Neglect of a child might manifest in frequent absences from school. This is a red flag of neglect because no one is making sure that this child is going to school.
A child who is begging for food, or stealing food or money, is attempting to meet their own needs because their needs are not being met by their caregiver, another sign of neglect.
Unclean clothes, excessive body odor, and poor dental health could indicate neglect. As could a child who is dressing inappropriately for the weather
You can read more about nursing care for children who have been abused here.
Hi, I'm Meris, and in this video, I'm going to be talking to you about different types of child abuse, and the reporting requirements, and the signs of that abuse. So I just want to give you a big trigger warning, a big heads up before we get into any sort of content that the entire content of this video focuses on child abuse. So if that is triggering content to you, I would suggest skipping this video in its entirety. This is going to be sad content regardless, but if this is going to be triggering to you, please do not watch it. I'm going to be following along using our pediatric nursing flashcards. These are available on our website leveluprn.com. If you already have a set, I would invite you to follow along with me. And if not, go check out leveluprn.com to grab a set for yourself. All right, let's get started.
So first up, we're going to be talking about the different types of abuse, along with risk factors for abuse. So types of abuse we have, we're going to be talking about four different ones. We have physical abuse, which is the intentional use of physical force against a child. So for instance, this could be hitting, kicking, shaking, burning, anything that could cause physical harm to a child. We have emotional abuse where we have behaviors that could harm a child's self-worth or self-esteem or their emotional well-being, such as name-calling, shaming, or rejection. We have sexual abuse, which would be forcing a child to engage in sexual acts such as fondling or penetration. And lastly, we do have neglect. And neglect is a little bit different in that this is failure to meet a child's basic physical needs. So this could be not providing housing or food, education, and even access to medical care is a form of neglect. Now, when we talk about risk factors, I want you to understand that these risk factors are just based on the aggregation of data. This does not mean that somebody with these specific risk factors is going to abuse a child. It's just things that have been shown through data to be linked to something like abuse. So I just want to put that out there because some of these things could be upsetting to somebody if they say, "Well, I fall into that category." It does not mean that you are an abuser. These are just possible risk factors. So first up, children who are less than four years old or who have special needs, such as if they have illnesses or disabilities, these children are more at risk for abuse. If you think about the kinds of children that are the most demanding are going to be those less than four, right? An infant cries frequently. A child less than four means a lot of attention and can have a lot of high needs, along with a child who has an illness or disability. So that can put them at risk for abuse. A family history of mental health issues or substance abuse can put a child at risk for abuse as well. Inconsistent, transient, or non-biological caregivers are also risk factors, as well as parents with low income or education levels, teenage parents, single parents, and parents who have many other young children. So all of those are possible risk factors for abuse.
Now when we talk about abuse, we need to talk about the signs of abuse in our requirements as nurses to report abuse. Now we're going to talk about signs of specific type of abuse in a moment. These are just general signs of abuse to keep in mind. Big one year, bold red text. Incompatibility between the story and the injury. So if the story and the injury don't match, that is a big red flag for potential abuse, right? We need to investigate that further inconsistent story between the child and the caregiver. So if the caregiver says one thing, but the child says another, even if neither one of them is saying anything about abuse, the inconsistency in the stories is a big red flag that this could be from abuse. Injuries that are extremely unlikely, given a child's developmental age. So the example we give here is a two-month-old who quote, "Crawled off the bed and hit his head." Right? That's very unlikely. A two-month-old can't crawl, right? It's possible for a two-month-old to fall off a bed. But this language of crawling is unusual. A child with burn injuries, if it's like a four-month-old, and they say that the "child must have turned the bathwater on and fallen in," that's very unlikely. It doesn't make sense, given the child's developmental age. Injuries that could have been avoided with basic parental supervision. This is another red flag for abuse. Now what is our job as nurses when it comes to reporting abuse? So this is so important to understand. Nurses are required to report the suspicion of abuse. So you do not need to have proof of abuse to report it. You just need to have the suspicion. The burden of proof does not lie on the person who reports it. So just because you report it does not mean you have to prove it. But you are a mandated reporter, meaning it is mandatory, it is required that you report abuse suspected abuse of a child, right, of any form. This is very important. You just need to give the facts in the circumstances that lead you to have this suspicion. But you don't have to give any sort of proof, right? Now if there is proof that is supporting evidence as well, but you just have to have the suspicion of abuse.
Okay. Moving on, we're going to talk about different signs of abuse here. So signs of physical abuse. If we have multiple injuries that are in various stages of healing, maybe we have multiple fractures or a lot of bruises, and they're all in different phases of healing, that could be a sign of abuse. Bruises on the cheek, neck, genitals, buttocks, or back. Those are all possible signs of abuse because, remember, that kids get a lot of bruises when they're little, right, but most accidental bruises for over bony provinces like the knees or elbows or shins-- my daughter is covered in bruises on her shins, right, because she is a preschooler. She's running around doing all kinds of stuff. She's got bruises on her legs, but she does not have them in these soft tissue areas, right? That's a big red flag. Bruises in the shape of a causative object, such as a belt, burns in the clear shape of an object. So, for instance, on an iron, right, that gives that pattern of an iron, or a cigarette burn, or what we call immersion burns. So if you put a child in hot water intentionally to cause pain that leads to burning, we would see those immersion burns, which means that they have a clear line of demarcation, meaning here's the burn, right, it goes all the way up to here. It stops. Nothing is burned here. That's what an immersion burn looks like. And then big, big, important thing to remember is that spiral fractures-- spiral fractures do not typically happen to a child without a twisting motion. So this is going to be something like grabbing a child by the arm and twisting and pulling up that could cause a spiral fracture versus they're playing on the playground and they fall down and break their arm. It's going to be a different type of fracture. There are some exceptions to this rule. And, again, that would have to do with the injury matching the story, right? Now, signs of shaken-baby syndrome in particular, which is a type of physical abuse, but this is more specific type of abuse, would be poor feeding, irritability, lethargy. So they're very tired. They're hard to wake up, vomiting, seizures, periods of apnea, right, where they stop breathing, retinal hemorrhage. All of those are potential signs of shaken-baby syndrome that is very important to know so that you can catch that if you should ever see that.
Lastly, we're going to talk about signs of emotional and sexual abuse, and also signs of neglect. So signs of emotional abuse. We might have a child with extreme behavior, so either they're overly compliant or very demanding. Maybe they are very passive or very aggressive, right? We're on either extreme here. Or delayed physical or emotional development. If we have a child who is not having their emotional needs met, they may not be developing emotionally the way we would anticipate. Now, signs of sexual abuse. Difficulty walking or sitting is going to be a big red flag here for sexual abuse. If a child exhibits advanced understanding or behavior sexually for their age, if a young child tells you about specific sexual behavior or is seen demonstrating or attempting to demonstrate that behavior, especially with other children, that should be a big red flag as well. If a child has a sexually transmitted infection, of course, that's going to be pretty obvious, but frequent urinary tract infections as well can be a sign of sexual abuse, especially in children with a vulva. And then new onset nocturnal enuresis, which means wetting the bed at night, right? So new-onset bedwetting can possibly be a sign of sexual abuse when it comes to neglect, though, things are going to be a little bit different. Frequently absent from school. That is going to be a big red flag of neglect. Nobody's making sure that this child is going to school. They are being neglectful. A child who is begging for food, or stealing food or money, right. Again, they're trying to meet their own needs because they're not being met by their caregiver. Unclean clothes, excessive body odor, poor dental health. All of those could indicate neglect. And then a child who is dressing inappropriately for the weather, that could be due to neglect as well.
I hope that review was helpful for you. Stay tuned because I have some quiz questions to help you test your knowledge of key facts I gave you in this video. Okay. So first up, we have a child who states that their caregiver calls them names. They make fun of them and they shame them. How does the nurse characterize this type of behavior? What type of abuse or neglect might this child be experiencing? Next up, a nurse suspects that a child may be being abused by their caregivers, but they don't have proof of this. How should the nurse proceed? Thirdly, what type of fracture should be a red flag to the nurse as potentially being caused by physical abuse? What type of fracture did I tell you was a red flag for abuse? And lastly, when caring for a child, the nurse notes in their history that the child has had frequent urinary tract infections, and they seem to be having difficulty walking and sitting. What type of abuse might the nurse suspect in this case? Let me know how you did. I hope this review was helpful for you. Thanks so much, and happy studying.
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