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]


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.

What are age-appropriate normal sexual behaviors?

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