Signs & Symptoms of Abuse/Neglect
Behavioral clues:
- infants excessive crying or developmental delay
- fear, anxiety, clinging
- phobias
- nightmares, sleeping problems
- bed wetting
- social withdrawal
- hyperactivity
- poor concentration/distractibility
- decreased school performance
- chronic school absenteeism
- speech disorders
- regressive behavior for age
- seems afraid of parent
- eating issues
- depression, passivity
- increased verbal abuse or physically aggressive behavior with others
- destroys or injures objects or pets
- substance abuse
- self-harm such as cutting
- sexualized behavior
- symptoms of PTSD
- avoidance of undressing
- withdrawal to touch, afraid of exam
- overly compliant, especially with difficult or painful parts of the exam
Symptom clues:
- headaches
- abdominal pain, chronic
- abdominal pain, acute – blunt trauma may not show external marks – look for distention, tenderness, absent bowel sounds
- vague somatic complaints, often chronic
- worsening medical problems, such as asthma
- frequent, unexplained sore throat
- abnormal weight gain or loss
- reluctance to use an extremity
- difficulty walking or sitting
- genital discomfort or painful urination or defecation
- unexplained symptoms - look for poisoning, forced ingestion of water, salt (Munchausen by proxy)
- vomiting, irritability or abnormal respiration may represent head trauma
Physical clues (most common manifestations of abuse are found from skin, bone, or CNS):
- poor hygiene
- dressed inappropriately for weather
- failure to thrive, poor weight gain, malnutrition
- lack of care of medical needs; wound care, medication
- see fractures
- dislocations
- see bruising
- defensive injuries on forearms
- bites - human bites are more superficial than animal, and show up better 2-3 days later
- burns – (in 6-20% of abused children) cigarette, rope, immersion, or shape of hot object
- is the severity of the burn consistent with length of contact by history?
- cigarette burns circular, 8-10mm deep, heaped margin - may be confused with impetigo or moxibustion
- stun gun burns occur in pairs, 0.5cm diameter and 5cm apart
- immersion burns have sharp line of demarcation without drip or splash marks
- signs of restraints on axilla or extremities
- trauma to ear
- lacerations
- traumatic hair loss
- facial injuries without good explanation
- oral/dental injuries, such as torn or bruised frenulum, lips, teeth, palate, tongue or oral mucosa
- injuries from non-ambulatory child may be "bottle jamming"
- lacerations or tissue damage to oral structures may come from eating utensils, scalding or caustic liquids
- scarring/bruising at corners of mouth from being gagged
- oral injuries/STDs from forced oral sex
- head injury, mental status change
- retinal hemorrhage
- subdural hematoma
- intra-abdominal trauma, usually to multiple organs
- bruising, tearing, bleeding, discharge from genital or rectal area
- diagnosed STD or pregnancy
[Adapted from multiple sources listed in Resources and References]
Warning!
Parents may seem evasive or inconsistent in their story due to language or cultural differences, or to being embarrassed or afraid relating to some other issue. Cultural/language difficulties may also lead to delayed care.
Children may be injured by domestic violence via:
- being too small to get out of the way
- trying to intervene
- becoming an object of abuse
- being neglected by the abused parent, who may be focused on their own fear or depression
Red flags with injuries:
- explanation doesn’t fit the injury as to pattern, timing, or developmental ability of child
- explanation keeps changing
- child is consistently blamed as cause of repeated injuries
- significant injuries attributed to a young sibling
- delay in seeking medical care
- history of multiple ED visits
- frequent change of primary care provider
Parental risk factors:
- rigid, severe discipline
- strongly responds to negative behaviors, ignores child's positive behaviors
- ridicules child in public
- isolates child socially or from other family members
- seems overprotective or jealous
- unrealistic expectations of child development or behavior for age
- parent is caregiver for child with significant cognitive, physical or emotional disabilities
- child unwanted, unplanned
- lack of emotional interaction with child
- inappropriate over or under concern about injury
- partial confession
- depression
- difficulty controlling emotions, esp. anger
- substance abuse
- teen parenthood
- family stress such as divorce, job loss