This paper provides a comprehensive overview of child clinical intervention across two major areas. Part I examines the three primary forms of child abuse — physical, sexual, and emotional — detailing prevalence statistics, risk factors, behavioral and physical indicators, clinical symptoms, diagnostic tests, and mandated reporting requirements under federal and state law. Part II surveys three childhood developmental disorders: autism spectrum disorder, attention deficit hyperactivity disorder (ADHD/ADD), and Down syndrome. For each disorder, the paper discusses diagnosis challenges, known causes, prevalence, and available treatment approaches. Together, the two parts offer a broad reference for understanding how child maltreatment and developmental disorders are identified, reported, and addressed in clinical and educational settings.
Physical abuse of children occurs throughout every social stratum, although there may be an increased incidence among those living in poverty. Abuse often occurs at moments of great stress, when a perpetrator strikes out in anger at a child. The perpetrator may also have been abused as a child and may have poor impulse control. Because of the relative size and strength difference between adults and children, an abused child can be severely injured or killed. Abuse frequently occurs from shaking an infant, which causes bleeding over the brain (subdural hematoma) — a phenomenon commonly referred to as shaken baby syndrome.
The incidence of child abuse is remarkably high and fairly accurately reported. The total abuse rate is 25.2 per 1,000 children, with physical abuse accounting for 5.7 per 1,000, sexual abuse 2.5 per 1,000, emotional abuse 3.4 per 1,000, and neglect accounting for the vast majority at 15.9 per 1,000 children. Risk factors include poverty, lack of education, single parenthood, alcohol or drug abuse, and a host of other factors. However, child abuse occurs in all strata of society.
As this data from the National Institutes of Health makes abundantly clear, child abuse is a serious public health concern. Children are among the most vulnerable members of society. Given their impressionable nature, abused children can eventually become abusers themselves, perpetuating a vicious cycle that must be controlled and eliminated.
Examining perpetrators reveals a troubling pattern. More than 80% of victims (84%) were abused by a parent or parents. Mothers acting alone were responsible for 47% of neglect victims and 32% of physical abuse victims. Non-relatives, fathers acting alone, and other relatives were responsible for 29%, 22%, and 19% of sexual abuse victims, respectively. If child abuse were primarily committed by unknown third parties, extreme supervisory measures might suffice. However, since parents and relatives constitute the largest percentage of abusers, the problem raises the difficult question of who will guard the guardians — those who are naturally assumed to be most interested in a child's welfare.
Child fatalities are the most tragic consequence of maltreatment. Approximately 1,200 children died of abuse or neglect in the year 2000, a rate of 1.71 children per 100,000 in the population. The increase in fatality rates compared to earlier years is hypothesized to be largely attributable to improved reporting. Younger children were the most vulnerable: children under one year of age accounted for 44% of child fatalities, and 85% of child fatalities were younger than six years of age. When so many children are abused to the point of death, the problem demands serious attention. Child abuse is not merely another social problem — it attacks the core of decency and social behavior, and its self-reinforcing nature makes it all the more dangerous.
Physical abuse accounts for 19% of all substantiated cases of child abuse and is the most visible form of abuse. It may be defined as any act that results in non-accidental trauma or physical injury. Inflicted physical injury most often represents unreasonable, severe corporal punishment. This typically happens when a frustrated or angry parent strikes, shakes, or throws a child. Physical abuse injuries result from punching, beating, kicking, biting, burning, or otherwise harming a child. While any of these injuries can occur accidentally during play, physical abuse should be suspected if the explanations do not fit the injury or if a pattern of frequency is apparent. The longer the abuse continues, the more serious the injuries and the more difficult it becomes to eliminate the abusive behavior.
Mass media often portrays the physical child abuser as a monster, but such framing does little to help. Given the size and strength differential between abuser and child, serious damage can result. What further complicates detection is that children are naturally prone to minor injuries and often do not raise suspicion when hurt. A child may not realize he or she is being abused and may therefore not speak up. In many cases, the child may even be led to believe that the abuse is his or her own fault — compounding physical harm with emotional damage.
Physical indicators of physical child abuse include the following (none is individually deterministic; context, explanation, and frequency of occurrence all matter):
Bite marks; unusual bruises; lacerations; burns; high incidence of accidents or frequent injuries; fractures in unusual places; injuries and swellings to the face and extremities; discoloration of skin.
Behavioral indicators in the child may include: avoidance of physical contact with others; apprehension when other children cry; wearing clothing to conceal injuries (e.g., long sleeves); refusing to undress for gym or required physical exams; giving inconsistent versions of how injuries occurred; appearing frightened by parents; frequent lateness or absences from school; arriving early and seeming reluctant to go home; difficulty getting along with others; being overly compliant or withdrawn; playing aggressively and hurting peers; complaining of pain upon movement or contact; a history of running away; or directly reporting abuse by parents.
As many parents will recognize, a number of these behavioral characteristics can appear in children to varying degrees under ordinary circumstances — which is precisely why detecting physical child abuse is not straightforward.
Clinical symptoms that may indicate physical child abuse include: appearance at an emergency room with an injured child and an improbable explanation; delayed presentation at an emergency room; bruise marks shaped like hands, fingers, or objects such as a belt; specific patterns of scalding consistent with immersion in hot water; burns from stoves, radiators, or heaters on the child's hands or buttocks; cigarette burns on exposed areas or genitals; black eyes in an infant; human bite marks; lash marks; choke marks around the neck; circular marks around wrists or ankles from twisting; separated sutures or a bulging fontanel in an infant's head; and unexplained unconsciousness in an infant.
A physical examination may also reveal: multiple retinal hemorrhages; internal damage such as bleeding or organ rupture from blunt trauma; fractures in an infant too young to walk or crawl; evidence of epiphyseal fractures (often multiple) of long bones or spiral fractures from twisting; fractured ribs; skull fractures (occasionally multiple fractures of different ages); and subdural hematoma without a plausible explanation. These findings will not by themselves confirm abuse versus accident, but they provide critical clinical clues and inform the course of treatment and therapy.
"Warning signs and forms of sexual and emotional abuse"
"Federal and Florida statutes on mandatory abuse reporting"
Every state and the District of Columbia have statutes identifying mandatory reporters of child maltreatment and the circumstances under which they are required to report. A mandatory reporter is a person required by law to make a report, though any person may report incidents of abuse or neglect. Today, reporting laws encompass all professionals working with children. Individuals typically designated as mandatory reporters include: physicians, nurses, hospital personnel, and dentists; medical examiners; coroners; mental health professionals and social workers; school personnel; law enforcement officials; and child care providers. In approximately 18 states, any person who suspects child abuse or neglect is required to report.
Every state has its own statute regarding mandatory child abuse reporting. The Florida statute provides a representative example:
Fla. Stat. Ann. § 39.201(1)
Who must report: Any person; physicians, osteopathic physicians, medical examiners, chiropractic physicians, nurses, or hospital personnel engaged in the admission, examination, care, or treatment of persons; other health or mental health professionals; practitioners who rely solely on spiritual means for healing; school teachers or other school officials or personnel; social workers, day care center workers, or other professional child care, foster care, residential, or institutional workers; law enforcement officers; or judges.
Circumstances: When they know, or have reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare.
Privileged communication (Fla. Stat. Ann. § 39.204): The privileged quality of communications between husband and wife and between any professional person and his or her patient or client — or any other privileged communications except those between attorney and client or communications to a clergy member for purposes of spiritual counsel — shall not apply to any communication involving a perpetrator or alleged perpetrator in any situation involving known or suspected child abuse, abandonment, or neglect. Such privilege shall not constitute grounds for failure to report, failure to cooperate with the Department, or failure to give evidence in any judicial proceeding relating to child abuse, abandonment, or neglect.
Autism was much misunderstood until recently. Originally, people regarded an autistic child as simply "crazy" or, more clinically, as mentally retarded. Even after autism was recognized as a distinct condition, treatment and cure remained elusive. Progress since then has been considerable. Today, treatment and therapy have substantially improved outcomes for autistic individuals, and there are now specialized schools equipped to nurture autistic children.
According to the CDC's Autism Information Center, autism spectrum disorders (ASDs) are a group of developmental disabilities caused by an abnormality in the brain. People with ASDs tend to have problems with social and communication skills. They are also likely to repeat certain behaviors and to resist change in their daily activities. Many people with ASDs have unusual ways of learning, paying attention, or reacting to different sensations. ASDs begin during childhood and last throughout a person's life.
Autism is found in every country and region of the world, and in families of all racial, ethnic, religious, and economic backgrounds. Emerging in childhood, it affects about 1 or 2 people in every thousand and is three to four times more common in boys than in girls. One of the important characteristics of autism is that infant autism may go totally undetected — children begin with a low level of speech, motor, and emotional development, and parents may not have a clear benchmark of what to expect at each stage.
Diagnosis: To date, there are no medical tests such as X-rays or blood tests that can detect autism, and no two children with the disorder behave the same way. Several conditions can cause symptoms resembling those of autism, so parents and pediatricians need to rule out other disorders including hearing loss, speech problems, intellectual disability, and neurological problems. Autism specialists use a variety of methods to identify the disorder: standardized rating scales, close observation of language and social behavior, structured interviews with parents about early development, and review of family photographs and videos. Specialists may also test for certain genetic and neurological problems. Diagnosis is challenging even for specialists, and the absence of intuitive benchmarks means a parent might either worry excessively about minor deviations or continue to overlook symptoms on the assumption that "all children are different."
Treatment: It is important to be patient and understanding with an autistic child. The world of an autistic child differs in significant ways — attention, focus, concentration, response to pain, and survival instincts can all be affected. Gone are the days when an autistic child had to be institutionalized. Methods are now available to help improve social, language, and academic skills. Although more than 60% of adults with autism continue to need care throughout their lives, some programs are beginning to demonstrate that with appropriate support, many people with autism can be trained to do meaningful work and participate in community life.
"ADHD prevalence, symptoms, and medication treatment"
"Causes, features, and care for Down syndrome"
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