Child Abuse, Autism, ADHD, and Down Syndrome: A Clinical Guide

Overview of Child Abuse: Prevalence and Perpetrators

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 Child Abuse: Indicators and Clinical Findings

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.