Behavioral Health

Child abuse and neglect: recognition and reporting

Clinical Overview and When to Suspect Child Abuse

— ~600,000 substantiated US cases per year; ~1,800 child fatalities annually, >70% under age 3

— Neglect is the most common form (~75% of substantiated reports), then physical abuse, sexual abuse, emotional abuse

— Highest fatality rate in infants <1 year; abusive head trauma peaks at 2–4 months

— Child: prematurity, disability, chronic illness, colicky infant, non-biological child in home

— Caregiver: young parental age, substance use, mental illness, intimate partner violence (IPV), social isolation, prior CPS involvement

— Environment: poverty, housing instability, recent job loss, deployment, single caregiver

— Injury inconsistent with developmental stage (e.g., femur fracture in a non-ambulatory infant)

— History that changes between tellings or between caregivers

— Delay in seeking care disproportionate to injury severity

— Injury mechanism doesn't match pattern (e.g., "rolled off couch" causing complex skull fracture)

— Multiple injuries at different stages of healing

— Sentinel injuries: any bruise, oral injury, or frenulum tear in a pre-cruising infant ("those who don't cruise rarely bruise")

— Recurrent ED visits, missed well-child checks, immunizations behind

Definition scope: Child maltreatment includes physical abuse, sexual abuse, emotional/psychological abuse, and neglect (medical, nutritional, supervisional, educational). All 50 US states mandate reporting by physicians on reasonable suspicion, not proof.

Epidemiology highlights:

Major risk factors:

When to actively suspect:

Step 3 management: Clinical suspicion alone triggers a CPS report — you do not need to determine who did it, prove intent, or wait for imaging. Reporting in good faith confers legal immunity in every state; failure to report is a misdemeanor and exposes the physician to civil liability.

Board pearl: A bruise on a <4-month-old infant is abuse until proven otherwise — these are sentinel injuries that, if missed, frequently precede fatal abuse within weeks.

Presentation Patterns and Key History

— Interview caregivers separately when feasible; document quoted statements verbatim

— Use open-ended questions ("Tell me everything that happened") before specifics

— Interview verbal child alone, in developmentally appropriate language, without leading questions — forensic interviewers preferred for sexual abuse history

— Document who was present, what was said, by whom, and timeline of care-seeking

— Inconsistent mechanism: explanation does not match injury pattern or severity

— Developmental mismatch: infant "climbed," "rolled off," "pulled the pot down" before they can do so

— Shifting history: mechanism changes with retelling

— Magical mechanism: "I don't know how it happened" for significant injury

— Blame on sibling/pet for severe injury

— Delayed presentation: hours to days after injury onset

Red-flag history elements (TEN-4-FACES or similar): Trunk, Ear, Neck bruising in any child ≤4y; any bruising in infant ≤4 months; Frenulum, Angle of jaw, Cheek, Eyelid, Subconjunctival hemorrhage.

History-taking technique:

Classic abuse history patterns:

Neglect-specific history: missed appointments, lapsed prescriptions (e.g., insulin, antiepileptics, asthma controllers leading to repeat DKA/seizure/admissions), failure to thrive with normal caloric intake history but flat growth curve, dental caries, untreated injury.

Sexual abuse history clues: age-inappropriate sexual knowledge or behavior, recurrent UTIs, dysuria, vaginal/anal bleeding, encopresis regression, anogenital STI in prepubertal child.

Psychological abuse: terrorizing, isolating, exploiting, denying emotional responsiveness — often coexists with IPV in home.

Key distinction: Accidental bruises cluster on bony prominences (shins, forehead, knees) in ambulatory children. Inflicted bruises cluster on padded/protected areas (ears, neck, cheeks, buttocks, genitals, posterior torso) and appear on pre-ambulatory children.

Board pearl: Document history in caregiver's own words with quotation marks. This becomes legal evidence.

Physical Exam Findings

— Patterned bruises (loop = cord/belt; linear parallel lines = hand slap; circumferential ligature marks at wrists/ankles)

— Bilateral, symmetric bruises (grab marks on upper arms or thighs)

— Pinna ("tin ear"), neck (choking), frenulum tear (forced feeding/blow to mouth)

— Bruises in clusters or in non-bony areas

— Bruise dating by color is unreliable — do not document age estimates

— Immersion burns: stocking/glove distribution, sharp waterline, sparing of flexion creases (child curled to protect), symmetric buttock/perineum with central sparing ("doughnut sign") from contact with cooler tub bottom

— Contact burns with mirror-image of object (cigarette = 7-10 mm round, full-thickness)

— Splash/spill accidental burns have irregular margins with satellite lesions

— Classic metaphyseal lesions ("bucket handle/corner")

— Posterior rib fractures (from anteroposterior thoracic compression)

— Scapular, sternal, spinous process fractures

— Any fracture in non-ambulatory infant

— Multiple fractures at different healing stages

Full skin survey with the child fully undressed in a gown; examine scalp, behind ears, oral cavity, frenula, genitals, perineum, soles, between fingers/toes. Photograph findings with measurement scale.

Bruising patterns suggestive of abuse:

Burns:

Bites: intercanine distance >3 cm = adult; swab for DNA before cleaning.

Oral injuries: torn frenulum in non-ambulatory infant is highly specific for inflicted trauma.

Fractures concerning for abuse:

Anogenital exam: majority of sexually abused children have normal exam; absence of findings does not rule out abuse. Hymenal transections at 3–9 o'clock and acute anogenital bruising are concerning.

Hemodynamic check: assess for occult abdominal trauma — hepatic/pancreatic injury from blows is a leading cause of abusive death after head trauma; check for abdominal bruising, tenderness, hypotension, tachycardia.

Board pearl: Posterior rib fractures in an infant are pathognomonic until proven otherwise — they require squeezing force and do not result from CPR.

Diagnostic Workup — Initial Labs and Imaging

— Any child <2 years with suspected physical abuse

— Children 2–5 years on case-by-case basis

— Not useful in children >5 years (use targeted imaging)

— Must include AP/lateral skull, cervical/thoracic/lumbar spine, chest (AP + obliques for ribs), pelvis, and each long bone individually, hands and feet — a "babygram" is inadequate

— Non-contrast head CT for any infant with suspected abusive head trauma, altered mental status, scalp swelling, or unexplained vomiting/seizures

— MRI brain within 2–3 days adds sensitivity for shear injury, subdural hematomas of differing ages, and timing

— AST, ALT (>80 IU/L → CT abdomen/pelvis with contrast)

— Lipase, amylase

— UA for hematuria

Skeletal survey is mandatory for:

Repeat skeletal survey in 2 weeks improves yield by ~20% (rib fractures, CMLs become visible with callus).

Neuroimaging:

Labs for occult abdominal trauma (any infant with suspected abuse):

Bleeding workup if bruising prominent: CBC, PT/INR, aPTT, fibrinogen, vWF antigen/activity, factor VIII/IX — to rule out coagulopathy before attributing bruising to abuse.

Bone health labs if fractures unexplained: calcium, phosphorus, alkaline phosphatase, 25-OH vitamin D, PTH (rule out rickets, osteogenesis imperfecta).

Toxicology screen: urine and serum in altered/ill-appearing child; hair toxicology can detect chronic exposure.

Sexual abuse acute (<72–120 h): forensic kit collection, GC/CT NAAT (vaginal, rectal, pharyngeal), HIV/HBV/syphilis, pregnancy test in post-menarchal, wet mount.

Step 3 management: Order skeletal survey, head CT, LFTs, lipase, and coags simultaneously in any infant with suspected physical abuse — do not stagger. Admit for safety while workup proceeds.

Board pearl: Elevated LFTs (AST/ALT >80) in an infant without explanation is a screen for occult abdominal trauma — image the abdomen.

Diagnostic Workup — Advanced or Confirmatory Studies

— Detects diffuse axonal injury, hypoxic-ischemic injury, small subdurals missed on CT

— Identifies subdurals of differing ages (hyperacute, acute, subacute, chronic) — strong indicator of repeated trauma

— Cervical spine MRI: ligamentous injury from shaking

— Multilayered, multifocal retinal hemorrhages extending to the periphery are characteristic of abusive head trauma (shaking)

— Distinguish from birth-related (resolve <4 weeks), increased ICP (typically posterior pole), or accidental trauma (rare, focal)

— Document with RetCam photography when available

— Child Abuse Pediatrics (CAP-boarded) — gold standard

— Pediatric ophthalmology, radiology, neurosurgery, forensic nursing (SANE), social work

MRI brain and cervical spine (within 2–5 days of presentation):

Dilated retinal exam by ophthalmology:

Repeat skeletal survey at 10–14 days: identifies healing fractures not initially visible; recommended in all infants with high suspicion and equivocal initial survey.

Bone scan (technetium-99m): adjunct when skeletal survey negative but suspicion remains; better for rib and subtle long-bone fractures, less sensitive for skull and CMLs.

CT abdomen/pelvis with IV contrast if LFTs elevated, abdominal exam abnormal, or hemodynamic instability — evaluates for liver/spleen lac, pancreatic injury, duodenal hematoma, mesenteric tear.

Genetic/metabolic workup when osteogenesis imperfecta suspected: collagen biochemistry, COL1A1/COL1A2 sequencing — useful when blue sclera, dentinogenesis imperfecta, family history, or unexplained multiple fractures with normal bone density.

Genital exam under anesthesia rarely needed but considered for severe acute injury or to obtain evidence in non-cooperative young child.

Subspecialty consultation:

Key distinction: Retinal hemorrhages confined to the posterior pole in a few layers can occur with accidental trauma or birth; diffuse, multilayered, peripheral hemorrhages with retinoschisis are essentially diagnostic of inflicted shaking injury.

Risk Stratification and First-Line Management Logic

— Injury severity warrants

— Safe disposition is uncertain

— Workup incomplete (skeletal survey, ophthalmology, MRI)

— Siblings at home may be at risk — request CPS evaluation of all household children <2y (twin/sibling skeletal survey)

— High suspicion + dependent infant → admit

— Moderate suspicion + reliable outpatient follow-up + CPS engaged → may discharge to safe placement (often kin or foster) per CPS

— Sexual abuse acute (<72–120 h) → ED forensic kit, prophylaxis, admit if unsafe placement

Step 1 — Stabilize: ABCs first. Abusive head trauma and abdominal trauma carry highest mortality. Manage like any major pediatric trauma — neurosurgical and surgical consults as needed.

Step 2 — Document: detailed history (verbatim), exam (with body diagrams and photos), time of presentation, who brought child, who was present at injury.

Step 3 — Report: Make a verbal report to CPS and law enforcement as soon as reasonable suspicion arises (does not require completed workup). Most jurisdictions require written follow-up within 36–48 hours. The threshold is "reasonable cause to suspect" — not proof.

Step 4 — Protect: Do not discharge the child until safety is ensured. Admit if:

Step 5 — Coordinate: activate hospital child protection team, social work, child abuse pediatrician.

Disposition decision tree:

Mandated reporter status: physicians, nurses, social workers, teachers, clergy (in most states), childcare workers. Reporting in good faith is legally protected; failure to report is criminal (misdemeanor → felony in some states) and grounds for licensure action.

CCS pearl: On a CCS case suggesting abuse, the first three orders should be (1) head CT or skeletal survey as age dictates, (2) social work / CPS consultation, (3) admit for safety. Discharging home is a critical error even if injuries are minor.

Board pearl: Reporting suspected abuse does not require parental consent, and you do not need to inform the parents before reporting — though best practice is to inform them respectfully when safe.

Pharmacotherapy and Acute Medical Management

— HIV post-exposure prophylaxis (nPEP): 3-drug regimen × 28 days, start within 72 h (ideally <2 h). Pediatric regimen: tenofovir/emtricitabine + raltegravir or dolutegravir (weight-based). Baseline HIV test, repeat at 6 wk, 3 mo.

— STI prophylaxis (per CDC 2021): ceftriaxone 500 mg IM (1 g if ≥150 kg) + doxycycline 100 mg PO BID × 7 d (≥8 y) or azithromycin 1 g PO ×1 (<8 y) + metronidazole (post-menarchal). Prepubertal children: often defer empiric treatment until NAAT results because base rate of STIs is low and findings have evidentiary weight.

— Emergency contraception: levonorgestrel 1.5 mg PO ×1 (≤72 h) or ulipristal acetate 30 mg (≤120 h) in post-menarchal patients; copper IUD up to 5 d.

— Hepatitis B: complete series if unvaccinated; HBIG if perpetrator known HBV+.

— HPV vaccination if not up to date.

— Tetanus update if penetrating injury.

There is no drug that treats "abuse" — pharmacotherapy targets specific injuries and prophylaxis. Always include:

Pain control: age-appropriate acetaminophen, ibuprofen; opioids for severe trauma (morphine 0.05–0.1 mg/kg IV).

Sexual abuse — acute presentation (within 72–120 h):

Abusive head trauma: standard TBI management — head of bed 30°, normocapnia, normothermia, seizure prophylaxis with levetiracetam 20 mg/kg load if cortical injury or seizure; hypertonic saline 3% for ↑ICP; neurosurgical consult for evacuable hematoma.

Failure to thrive from neglect: controlled refeeding to avoid refeeding syndrome (monitor phos, K, Mg); start ~50% of caloric goal, advance over days; multivitamin including thiamine.

Step 3 management: Document what you offered, what was accepted, and timing — refusal of prophylaxis by an adolescent is their right (with capacity) but must be carefully counseled and documented.

Procedures, Forensic Collection, and System-Level Interventions

— Acute kit indicated <72 h (some jurisdictions extend to 120 h or 7 d for adolescents)

— Performed by SANE (Sexual Assault Nurse Examiner) or trained child abuse pediatrician

— Chain of custody is critical — evidence sealed, signed, transferred directly to law enforcement

— Bite marks: photograph with scale, swab for saliva DNA before cleaning

— Clothing collected in paper bags (not plastic — degrades DNA)

— Hospital Child Protection Team activation

— CPS report (verbal then written) — required by law

— Law enforcement notification — required for suspected abuse in most states; mandatory for sexual assault

— Multidisciplinary Child Advocacy Center (CAC) referral for forensic interview — minimizes re-traumatization through repeated questioning

— Sibling assessment: all children <2 y in household should undergo skeletal survey and exam; children 2–5 y at least clinical exam

Forensic evidence collection (sexual abuse):

Neurosurgical procedures: evacuation of subdural hematoma with mass effect or herniation; decompressive craniectomy for refractory ↑ICP; ventricular drain for hydrocephalus.

Exploratory laparotomy: indicated for hemodynamic instability with positive FAST, free air, or peritonitis from inflicted abdominal trauma.

Skin photography: body-diagram documentation plus photographs with ABFO No. 2 scale; serial photos at 24–48 h often reveal new bruising (bruises evolve).

System-level interventions:

Safe placement coordination: with CPS — kinship preferred, then licensed foster care; never discharge to suspected perpetrator's custody.

CCS pearl: Order "consult social work," "consult child protective services," and "consult child abuse pediatrics" as parallel actions; advance the clock only after these are placed and child safety is documented.

Board pearl: Photo-document with scale, in good lighting, including identifying anatomy. Photographs are routinely admitted as evidence; verbal description alone is insufficient.

Special Populations — Children with Disabilities and Chronic Illness

— Higher caregiver demand and burnout

— Communication barriers limit child's ability to disclose

— Increased exposure to multiple caregivers (respite, school aides, transport)

— Behavioral and feeding challenges that frustrate caregivers

— Diagnostic overshadowing — injuries or behavioral changes attributed to underlying condition

— Autism spectrum disorder

— Intellectual disability

— Cerebral palsy (especially nonambulatory) — feeding tube/gastrostomy complications used to mask neglect

— Deaf/hard-of-hearing

— Medically complex children (tracheostomy, central lines, ventilator-dependent) — medical child abuse (factitious disorder imposed on another) more common

— Caregiver (usually mother) fabricates, exaggerates, or induces illness

— Multiple specialists, multiple hospitals, "doctor shopping"

— Symptoms only in caregiver's presence

— Caregiver appears medically knowledgeable, oddly enthusiastic about procedures

— Child improves when caregiver removed

— Workup: separate child from caregiver and observe; review prior records for inconsistencies; covert video monitoring is controversial and used only with legal/ethical oversight

Children with disabilities are at 3–4× greater risk of all forms of maltreatment than typically developing peers. Why:

High-risk subgroups:

Medical child abuse / factitious disorder imposed on another:

Hepatic/renal impairment: rare consideration in maltreatment specifically, but matters for drug dosing in injured children (renally cleared antibiotics for STI prophylaxis, hepatically metabolized analgesics).

Elderly relevance: Although topic is pediatric, parallel adult forms exist — elder abuse is also mandatorily reportable in most states (separate hotline). Vulnerable adult laws apply to adults with cognitive/physical disability >18.

Key distinction: In medical child abuse, the perpetrator's motive is psychological gain from the sick role of the child, not financial — distinguishes from malingering by proxy (e.g., for disability benefits), which is also reportable but legally distinct.

Board pearl: Inconsistent histories across specialists and hospitals in a child with chronic illness should prompt records review for medical child abuse — request all outside records.

Special Populations — Adolescents, Infants, and Cultural Considerations

— Highest fatality rate; abusive head trauma peaks at 2–4 months coinciding with peak infant crying ("period of PURPLE crying" prevention initiative)

— Sentinel injury principle: any bruise on a pre-cruising infant is a major red flag

— Risk highest in crying infants, premature infants, multiples, infants with disability

— Burn and bruise injuries predominate

— Toilet-training–related abuse common (immersion burns, perineal injury)

— Recognize as victims — they may be dismissed as "behavioral problems"

— Dating violence (1 in 10 high schoolers); screen confidentially

— Sex trafficking: runaway, multiple STIs, tattoos/branding, accompanied by controlling older "boyfriend," no ID, scripted answers

— Confidentiality: adolescents may consent to STI testing, contraception, mental health care without parental consent in most states; abuse reporting overrides confidentiality

— Coining (cao gio): linear ecchymoses from rubbed coin; Southeast Asian; not abuse

— Cupping (ba guan): circular ecchymoses; Middle Eastern, Asian; not abuse

— Moxibustion: burns from herb burning over acupoints; can cause significant injury but typically not abuse

— Mongolian spots (congenital dermal melanocytosis): blue-gray pigmentation, present at birth, fade; NOT bruises

— Even with cultural practice, document and educate — repeat severe injury may still warrant intervention

Infants (<1 year):

Toddlers (1–4 y):

Adolescents:

Cultural practices — distinguish from abuse:

Pregnancy: Pregnant adolescents — screen for sexual abuse if <13 or partner significantly older (statutory rape laws mandate reporting depending on age differential per state).

Step 3 management: When a 14-year-old presents pregnant or with an STI, ask age of partner. If partner age exceeds legal threshold per state statutory rape law, mandatory report applies independent of consent.

Board pearl: Mongolian spots are commonly mistaken for bruises in non-White infants — document at birth/well-child to avoid future misidentification.

Complications and Adverse Outcomes

— Abusive head trauma: ~25% mortality; >50% of survivors have permanent neurologic disability

— Abdominal trauma: second leading cause of abuse fatality; duodenal/pancreatic injury commonly delayed-presentation

— Intracranial: subdural hematoma, diffuse axonal injury, hypoxic-ischemic injury, seizures

— Skeletal: nonunion, growth disturbance from physeal injury, deformity

— Burns: scarring, contractures, hypertrophic scars, need for grafting

— Spinal cord injury from cervical hyperflexion/extension during shaking

— Chronic pain

— Recurrent UTIs from anatomic injury (sexual abuse)

— Cognitive impairment, learning disabilities from TBI

— Visual impairment from retinal damage

— Adverse Childhood Experiences (ACEs) score correlates dose-dependently with adult depression, suicide, substance use, IPV perpetration, cardiovascular disease, autoimmune disease, premature mortality

— PTSD, complex trauma, dissociation

— Anxiety, depression, conduct disorder

— Attachment disorders (reactive attachment, disinhibited social engagement)

— Substance use disorders (3–4× risk in adulthood)

— Suicidality (≥4 ACEs: 12× suicide attempt risk)

Acute mortality:

Acute morbidity:

Long-term physical sequelae:

Long-term mental health sequelae (the "ACE" framework):

Reproductive and sexual: earlier sexual debut, teen pregnancy, sexual risk-taking, revictimization.

Intergenerational transmission: abused children at higher risk of becoming abusive parents — not deterministic; protective factors (one supportive adult, mental health treatment) substantially mitigate.

Educational/economic outcomes: lower educational attainment, employment, income; higher justice system involvement.

Recurrence: Without intervention, ~50% of abused children experience repeat abuse within 1 year, and severity often escalates.

Board pearl: Missing a sentinel injury (small bruise or oral injury in an infant) is associated with an estimated 30% risk of subsequent severe abuse — including fatality — within weeks. Acting on small injuries prevents catastrophic ones.

When to Escalate — Admission, ICU, and Consultations

— Reasonable suspicion of physical abuse in any infant <12 months

— Need to complete workup (skeletal survey, MRI, ophtho) safely

— Disposition not yet secured by CPS

— Sexual abuse with unsafe home placement

— Failure to thrive requiring observed feeding and refeeding monitoring

— Concern for medical child abuse (separation observation)

— Abusive head trauma with altered mental status (GCS ≤13), seizure, or imaging findings of mass effect

— Solid organ injury requiring serial labs/imaging or active bleeding

— Hemodynamic instability

— Need for ICP monitoring or surgical intervention

— Child abuse pediatrician (CAP-boarded) — coordinates evaluation, provides expert testimony

— Social work — assesses psychosocial context, coordinates with CPS

— Pediatric ophthalmology — dilated funduscopic exam for AHT

— Pediatric radiology — interprets skeletal survey, distinguishes mimics

— Neurosurgery — evacuation of hematomas, ICP management

— Pediatric surgery / trauma — abdominal injuries

— Hematology — if bleeding disorder workup positive or equivocal

— Genetics/metabolic — if OI or rickets suspected

— Psychiatry/psychology — child trauma assessment, caregiver evaluation

— Forensic interviewer / Child Advocacy Center — for verbal disclosures

— Verbal CPS report (immediate)

— Written CPS report within statutory window (24–48 h typically)

— Law enforcement (when state requires or for severe/sexual abuse)

— Hospital risk management / ethics consult if family conflict over workup

Admit (inpatient) any of the following:

PICU criteria:

Consultations to activate:

System notifications:

CCS pearl: In a CCS case of suspected abuse, never discharge home before CPS clears placement, even if labs and imaging are reassuring. Discharging to an unsafe environment is a major safety violation that drops the score.

Key Differentials — Mimics of Physical Abuse

— Coagulopathies: hemophilia A/B, von Willebrand disease, ITP, leukemia, vitamin K deficiency of the newborn — order CBC, PT/INR, aPTT, vWF panel before concluding abuse

— Henoch-Schönlein purpura (IgA vasculitis): palpable purpura on extensor surfaces and buttocks, with arthralgia, abdominal pain, hematuria

— Mongolian spots (dermal melanocytosis): congenital, slate-blue, sacral/buttock, fade by age 5

— Phytophotodermatitis: linear/bizarre hyperpigmentation after citrus/plant contact + sun exposure

— Erythema multiforme, fixed drug eruption

— Osteogenesis imperfecta: blue sclera, dentinogenesis imperfecta, hearing loss, family history, low-impact fractures with osteopenia; types II and III often present in infancy

— Rickets: widened, frayed metaphyses (can mimic CMLs), bowing, low 25-OH vitamin D, elevated alk phos, low/normal calcium

— Copper deficiency (in preterm or malabsorption): osteopenia, fractures

— Menkes disease: kinky hair, hypotonia, fractures

— Caffey disease (infantile cortical hyperostosis): cortical thickening of mandible and long bones

— Birth-related fractures: clavicle, humerus — heal by 2–3 weeks

— Glutaric aciduria type 1: subdural collections, macrocephaly — order organic acids

— Benign external hydrocephalus with subdural — usually asymptomatic

— Coagulopathy with spontaneous bleed

— Bullous impetigo, staph scalded skin

— Diaper dermatitis severe

Bruising mimics:

Fracture mimics:

Head trauma mimics:

Burn mimics:

Sudden infant death: SIDS vs inflicted suffocation — autopsy and scene investigation distinguish; recurrent unexplained infant deaths in a family raise suspicion.

Key distinction: Osteogenesis imperfecta type IV (mild form) can present with fractures and normal sclera; if the story doesn't fit abuse perfectly, send collagen testing — but simultaneously protect the child while workup proceeds.

Key Differentials — Behavioral and Psychiatric Mimics

— Organic failure to thrive: cystic fibrosis, celiac, eosinophilic esophagitis, congenital heart disease, hyperthyroidism, HIV, IBD — distinguish via targeted workup; organic and nonorganic FTT often coexist

— Poverty without neglect: food insecurity, housing instability — assess for parental effort and seeking of available resources; report only when caregiver action/inaction endangers child

— Religious/cultural medical refusal: Jehovah's Witness blood refusal, Christian Science — courts can override for life-threatening pediatric situations

— Lichen sclerosus: atrophic, hypopigmented anogenital plaques, may bleed with friction; misidentified as trauma — classic figure-8 distribution

— Straddle injury: anterior, asymmetric, involves labia majora/clitoral hood, sparing posterior fourchette (which is more characteristic of penetrating injury)

— Urethral prolapse: prepubertal Black girls; donut of red tissue around urethra

— Group A strep perianal infection: perianal redness, fissures

— Pinworm: perianal itch and excoriation

— Autism: stereotypies, social withdrawal — not abuse, but children with autism are at higher abuse risk

— ADHD, ODD, conduct disorder — may coexist with trauma; assess ACE exposure

— Tic disorders

Neglect mimics — medical and social:

Sexual abuse mimics:

Behavioral mimics of trauma:

Apparent life-threatening events (BRUE): evaluate for accidental vs inflicted; if recurrent or witnessed only by one caregiver, consider medical child abuse / suffocation.

Munchausen by proxy / medical child abuse: symptoms inconsistent with exam, present only with one caregiver, multiple specialists, escalating workup driven by caregiver.

Drug exposure: unintentional ingestion vs intentional poisoning — toxicology, history of access, multiple presentations.

Key distinction: Poverty is not neglect. Distinguish between caregiver inability (resource gap) and caregiver unwillingness or recklessness (neglect). The former calls for social work and resource linkage; the latter, CPS report.

Secondary Prevention and Long-Term Planning

— Nurse-Family Partnership and home-visiting programs for high-risk new mothers — reduce abuse rates by ~40%

— Period of PURPLE Crying education at maternity discharge — reduces abusive head trauma

— Universal IPV screening at prenatal and postpartum visits

— Safe sleep counseling (also reduces SIDS misattribution)

— Parenting skills training, mental health support for caregivers

— Early intervention services (IDEA Part C, 0–3 y)

— WIC, SNAP, housing assistance linkage

— Parental substance use disorder treatment

— Maternal depression screening (Edinburgh, PHQ-9) at well-child visits

— Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) — first-line for child PTSD

— Parent-Child Interaction Therapy (PCIT) for young children

— Eye Movement Desensitization and Reprocessing (EMDR) for older children/adolescents

— Psychiatric medication if comorbid major depression, severe anxiety, or PTSD with impairment (SSRI — sertraline or fluoxetine first-line in pediatrics)

— Complete HIV nPEP × 28 days; HIV testing at 6 wk, 3 mo (4th-gen Ag/Ab) — if RNA used, sooner

— HBV vaccine series completion; HBV serologies

— HPV vaccination

— Repeat GC/CT NAAT at 2 weeks; syphilis serology at 4–6 wk and 3 mo

— Pregnancy test at 2–3 weeks post-exposure

— Individualized Education Program (IEP) assessment

— Early intervention referral for <3 y

— Trauma-informed schooling

Primary prevention strategies (population level):

Secondary prevention (at-risk identified):

Tertiary prevention (post-abuse):

Pharmacologic post-exposure (sexual abuse):

Educational and developmental supports:

Step 3 management: Discharge planning for an abused child must include (1) safe placement confirmation, (2) trauma therapy referral, (3) primary care follow-up within 1–2 weeks, (4) any indicated subspecialty follow-up (ophthalmology, neurology), (5) re-engagement with CPS case worker.

Follow-Up, Monitoring, and Counseling

— Primary care visit within 1–2 weeks of discharge — wound check, weight, neurodevelopmental screen

— Repeat skeletal survey at 10–14 days post-initial (if abuse confirmed/highly suspected)

— Trauma therapy initiation within 4 weeks ideally

— CPS case worker check-ins monthly minimum

— Specialty follow-ups:

– Ophthalmology at 4–6 weeks post-AHT

– Neurology / neurosurgery for any intracranial injury

– Developmental pediatrics at 6 months and 12 months

— Baseline, 6 weeks, 3 months HIV testing (and 6 months if 3rd-gen test used)

— Renal function (BMP) at 2 weeks (tenofovir nephrotoxicity)

— LFTs if symptomatic

— STI testing repeat at 2 weeks (GC/CT NAAT)

— Syphilis, HIV serologies at 6 weeks and 3 months

— Pregnancy test at 2–3 weeks

— Mental health follow-up within 1 week

— Weight checks weekly until consistent gain

— Growth chart plotting at every visit

— Caloric intake diary review

— ASQ or PEDS at well-child visits

— Brain injury sequelae often manifest months later — vigilance for new behavior, attention, learning concerns

— Trauma-informed parenting education

— Substance use treatment, IPV resources, parental mental health treatment

— Home visiting services

— Safe sleep, infant crying coping ("put baby down safely, walk away, call for help"), positive discipline, safe firearm and medication storage

Outpatient follow-up cadence after suspected abuse:

Monitoring after HIV nPEP:

Sexual abuse follow-up:

Failure to thrive monitoring:

Developmental surveillance:

Caregiver counseling (when child is in family-of-origin or with kin):

Anticipatory guidance:

Board pearl: A child who has been abused and returns home should be seen by primary care every 1–3 months for the first year — recurrence risk is highest in this window, and the PCP becomes a key surveillance point.

Ethical, Legal, and Patient Safety Considerations

— All 50 US states require physicians to report reasonable suspicion — not certainty, not proof

— Reporting in good faith confers civil and criminal immunity

— Failure to report is a criminal offense (misdemeanor → felony) and can result in licensure discipline and civil malpractice exposure if subsequent harm occurs

— Reporter identity is generally kept confidential by CPS, but may be disclosed in court proceedings

— HIPAA explicitly permits disclosure to CPS and law enforcement for suspected abuse — no parental consent required

— You may share records and photographs with CPS investigators

— Document what was shared, with whom, and when

— Adolescent consent: in most states, minors may consent to STI testing/treatment, contraception, mental health care, and substance use treatment without parental notification — but abuse reporting overrides confidentiality; inform adolescent before reporting when safe

— Refusal of care by caregiver when child has life-threatening injury — physicians can proceed under emergency exception; for non-emergent but necessary care, seek court order via hospital legal/ethics

— Forensic exam consent: adolescent capacity to consent for sexual assault exam varies by state; document assent in younger children

— Handoff between ED and inpatient team — explicitly communicate suspected abuse status to prevent inadvertent discharge

— Discharge to CPS-cleared placement only — name, address, phone documented

— Custody documentation in chart to prevent unauthorized pickup

— Treating physician may be subpoenaed as fact witness; child abuse pediatricians often serve as expert witnesses

— Document objectively, avoid editorializing, avoid bruise-dating, avoid certainty about perpetrator

Mandatory reporting law:

Confidentiality and HIPAA:

Informed consent edge cases:

Transition-of-care risks:

Physician's role in court:

Conscientious objection / cultural humility: physicians cannot opt out of reporting based on personal belief — reporting is a legal duty.

Step 3 management: When a parent refuses imaging or testing during an abuse workup, proceed with workup under emergency or court-ordered authority, contact CPS immediately, and involve hospital legal/ethics. Do not let refusal block evaluation — that itself is a red flag.

High-Yield Associations and Rapid-Fire Facts

"Those who don't cruise rarely bruise" — any bruise in pre-ambulatory infant is suspicious

TEN-4-FACESp rule for bruising in young children — body region + age screen for abuse

Posterior rib fractures = AP thoracic compression (squeezing) — pathognomonic for abuse; not caused by CPR

Classic metaphyseal lesion (CML / "bucket handle" / "corner fracture") — pathognomonic for abuse, from shaking or yanking limb

Retinal hemorrhages — multilayered, multifocal, peripheral — diagnostic of abusive head trauma when combined with subdural and encephalopathy

Subdural hematoma + retinal hemorrhages + encephalopathy = "triad" of abusive head trauma (formerly "shaken baby syndrome")

Subdurals of differing ages on MRI → repeated trauma

Frenulum tear in non-ambulatory infant = abuse until proven otherwise

"Doughnut sign" on buttocks = immersion burn (sparing of central skin in contact with cooler tub)

Stocking/glove burns with sharp waterline = forced immersion

Long bone fracture in non-ambulatory infant = abuse until proven otherwise (especially femur, humerus)

Bilateral parietal/occipital skull fractures crossing sutures = high-energy impact, often inflicted

Hepatic laceration with elevated AST/ALT = consider inflicted abdominal trauma in infants

Duodenal hematoma in a young child without major accidental mechanism = inflicted

Neglect is the most common type of maltreatment (~75%)

Infants <1 year have highest fatality rate

Sentinel injury in infant → 30% subsequent severe abuse risk if missed

Most sexually abused children have a normal anogenital exam — disclosure is the most important evidence

ACE score ≥4 → markedly elevated risk of adult depression, suicide, substance use, CVD

HIV nPEP must start within 72 hours, ideally <2 h; STI prophylaxis per CDC

TF-CBT is first-line therapy for pediatric PTSD

Mandatory reporters have immunity for good-faith reports

You report on suspicion, not proof — CPS investigates, you don't

Board pearl: Memorize three pathognomonic findings — classic metaphyseal lesion, posterior rib fractures, multilayered retinal hemorrhages. Each independently warrants a CPS report.

Board Question Stem Patterns

— 6-week-old infant with bruise on cheek; parents say "rolled into crib bars." Next step?

— Answer: Skeletal survey, head CT, LFTs, coags, dilated funduscopic exam, social work, CPS report, admit — not "reassure and discharge"

— 3-month-old with femur fracture; "fell off the couch." Next best step?

— Answer: Skeletal survey, child abuse evaluation; non-ambulatory infant cannot self-mobilize to a couch

— 4-month-old with lethargy, seizure, bulging fontanelle, retinal hemorrhages, subdural; "fell from high chair."

— Answer: Most likely diagnosis = abusive head trauma; next step = head CT, admit PICU, neurosurgery, CPS report

— 14-year-old presents 36 hours after sexual assault. Most appropriate next steps?

— Answer: Forensic exam by SANE, HIV nPEP within 72 h, STI prophylaxis (ceftriaxone + doxy + metronidazole), emergency contraception, HBV vaccine, HPV vaccine, mental health support, mandatory report

— Infant with multiple fractures, blue sclera, family history of fractures. Diagnosis?

— Answer: Osteogenesis imperfecta — order collagen genetic testing; do not report as abuse without further workup, but ensure child safety in parallel

— Toddler with failure to thrive, parent is working two jobs, food insecure. Next step?

— Answer: Social work, WIC, EI referral, frequent weight checks — not immediate CPS report unless evidence of caregiver willful neglect

— A pediatrician suspects abuse but is unsure. What is the threshold?

— Answer: Reasonable suspicion — report; good-faith immunity applies

— 15-year-old discloses sexual relationship with 25-year-old. Action?

— Answer: Mandatory report (statutory rape) despite "consent"

— Parent refuses skeletal survey on infant with suspicious bruise. Next step?

— Answer: Notify CPS, obtain court order or proceed under emergency authority; do not discharge

Stem 1 — Sentinel bruise:

Stem 2 — Inconsistent history:

Stem 3 — Abusive head trauma:

Stem 4 — Sexual abuse acute:

Stem 5 — Mimicker:

Stem 6 — Neglect vs poverty:

Stem 7 — Mandatory reporting:

Stem 8 — Adolescent confidentiality:

Stem 9 — Refusing parent:

Board pearl: When the stem includes any non-ambulatory infant + bruise/fracture/oral injury, the correct answer is essentially always report + full abuse workup + admit — even if other answer options sound reasonable.

One-Line Recap

The Step 3 imperative for child maltreatment is to recognize sentinel injuries early, perform a structured workup (skeletal survey, head CT, dilated funduscopic exam, LFTs, coagulation studies, sexual-abuse prophylaxis when indicated), and file a CPS report based on reasonable suspicion alone — failure at any step puts the child at high risk of fatal recurrence.

Recognize: any bruise on a pre-cruising infant, classic metaphyseal lesions, posterior rib fractures, multilayered retinal hemorrhages, frenulum tears, patterned burns, and histories inconsistent with development or mechanism are red flags — neglect (the most common form) often presents as missed appointments, failure to thrive, and untreated chronic disease.

Workup: skeletal survey for all suspected physical abuse cases under 2 years (repeat in 10–14 days), non-contrast head CT plus MRI for any infant with neurologic concern, dilated fundus exam by ophthalmology, LFTs/lipase to screen for occult abdominal trauma, coagulation panel to rule out bleeding disorders, and sexual-abuse forensic kit with HIV/STI/pregnancy prophylaxis within 72–120 hours.

Report and protect: mandatory CPS report on reasonable suspicion — not proof — with good-faith immunity, admit any infant whose disposition is not safely secured, evaluate all sibling children under 2 in the home, coordinate with social work, child abuse pediatrics, law enforcement, and the Child Advocacy Center.

Plan longitudinally: trauma-focused CBT, primary care follow-up every 1–3 months in the first year, repeat skeletal survey, ACE-informed mental health surveillance, secondary prevention through home visiting, parental substance/mental health treatment, and IPV resources — because the child who survives missed sentinel injury is the one most likely to die from the next assault.

Board pearl: When in doubt, report, admit, and image — these three actions, taken together, prevent the missed catastrophic outcome that defines this topic.