A busy pediatrician looked troubled and tense. He had seen this five-year old, Angela, once before two years ago. Then, it was a fall from some playground equipment her mother had said. Today, mom reported that it was a fractured wrist due to a fall from Angela’s bicycle. However this didn’t explain the child’s two swollen black eyes.
Angela’s mother was a young adult who had dropped out of school. She was the mother of three and worked part-time as a waitress. Money was always limited. The pediatrician assumed that the current pandemic lockdown had increased the family’s stress, but he could not overlook today’s medical presentation.
He spoke to Angela’s mother about his concerns. At first she denied any abuse of Angela, but the mother then quickly dissolved into tears. She confessed to being overwhelmed by life’s circumstances as well as by her own limited resources. The doctor filed for protective services for Angela and supportive services for her mother. Child abuse remained a serious public health concern, he thought. It never seems to end.
This inference is correct. Child abuse in the U.S. remains a significant health concern. In 2021, the United States Department of Health and Human Services published the child abuse data for 2019, the last full year of reported data. There were 707,561 confirmed cases of child abuse. Of these, 74.8% were cases of neglect, 17.5% were cases of physical abuse, 9.3% were cases of sexual abuse, and 6.1% were cases of psychological maltreatment. There were 1,840 confirmed deaths of children due to abuse and neglect. Over 91.4% of this abuse was inflicted by parents. As staggering as these findings are, researchers know that child abuse remains significantly under-reported.
Child Abuse: A Brief Overview
Domestic violence (see my preceding essay, “Domestic Violence, Natural Disasters, and Health Care Providers”) is defined as the intentional infliction of harm by one family member upon another. Child abuse is another virulent form of domestic violence in which parents, who are charged with providing safety and care for their children, instead inflict harm [1, 2].
Paradoxically, child-abuse reports decline during natural disasters, such as the COVID-19 pandemic. The abuse does not decline but its reporting does. During lockdowns, there are no teachers, no coaches, no band-directors, no social workers with whom to interact and tell. Abused children are prisoners in their own homes and are forced to live with their assailants. As lockdowns are lifted children have people to tell, and reports of abuse are then filed.
There is no typical child-abusing parent. They include all genders, all social classes, all races, and all faith-traditions. Many are young, have limited education, and have poor coping skills in general. Substance abuse is often present as is untreated posttraumatic stress disorder (PTSD)  in one or both parents. Some abusers are entitled and narcissistic. Abuse often increases in the face of increasing parental stress. This is often the case in the face of unemployment, inadequate housing, or other material shortages.
Types of Abuse. The catalogue of types of abuse is lengthy and varied. Physical abuse refers to the infliction of bodily harm and includes slapping, punching, kicking, choking, stomping, overdosing, hurling the child across the room, hurling scalding liquids, hitting with cattle prods, burning with cigarettes, and the like. Sexual abuse refers to any unwanted sexual overtures. This includes petting, oral sex, and forced entry into an open-body cavity. (It becomes incest if the assailant is a parent or legal guardian.) Abuse also includes verbal/oral and nonverbal threats of harm with verbal/oral threats having been shown to alter brain structures.
In 2018, the U.S. federal government also began to keep data of child trafficking for purposes of forced child labor or sexual entrapment. This catalogue also includes neglect, which is the most prevalent form of child abuse. Neglect may include the neglecting of physical safety, housing, food insecurity, clothing, health, as well as basic education, the essential needs to foster normal growth and development. Lastly, there is willful murder of one’s own flesh. Murder of infants is usually committed by the mother; murder of teenage children is usually committed by the father. There is also murder by neglect in withholding acts of the basic necessities of life over time until, death ensues. Although any child may be a potential risk for these types of abuse, some children are at increased risk. Included here are congenitally malformed babies, children with special needs or physical/developmental delays, illegitimate children, and unwanted children.
Warning Signs. These various malicious violent acts leave signs of abuse that should be known by health care providers of all disciplines. These signs do not necessarily indicate child abuse but should be examined in detail, especially if the given explanation of the harm does not adequately explain the injury or injuries observed. Bruises are the most common form of possible child abuse, especially the presence of multiple bruises. Other markings include burns, head injuries, multiple fractures, unusual markings such as from electric cords or burns from cigarettes, overdosing, and intense psychological states of anger, aggression, bullying, anxiety, panic, and depression.
Long-term Consequences. If left untreated, the long-term effects of child abuse can be present throughout the lifespan into old age. These consequences can be both psychological and physical. In the psychological domain, there are states of anxiety with or without panic attacks, depression with or without suicidal intent, untreated PTSD , and states of impaired concentration and memory. Untreated abuse also increases inflammation in the body. This may lead to heart disease, diabetes, liver disease, chronic lung disease, irritable-bowel syndrome, asthma, obesity, chronic pelvic pain, migraine headaches, and fibromyalgia . Another major legacy of untreated child abuse is subsequent family violence. Research  has shown that victims of untreated child abuse go on to abuse their own children in 66% of the cases.
Health Care Providers and Child Abuse
Given that child abuse is such a prevalent issue, health care providers are likely to encounter these victims in their various practices. A few general principles may prove of assistance.
1. If you see signs of possible child abuse, listen carefully to the child and/or the parent or legal guardian to see if the explanation of what has happened can account for the observed injuries. Study the parent/child interaction. Is it warm and supportive? Is it indifferent? Is it outright hostile? Look for inconsistencies.
If you remain concerned that it may be possible child abuse, obtain a second opinion. If you and your colleague are in agreement, then request a child-abuse work-up in an emergency room or outpatient clinic, and report your observations. Inform the parent/legal guardian of what you are doing, and file your state’s necessary paperwork. Remain available to answer any questions from other doctors and medical colleagues, police, and/or child protection advocates.
These procedures are in the best interests of the child, your practice, and your agency. Your documentation protects your license and any possible related lawsuits. If standard practices are in place at the time of your assessment from a natural disaster or pandemic, observe basic practices as required.
2. If you and/or your agency routinely work with children, you or some colleague in your agency should be designated as the contact person for other agencies also working with children. These agencies may include pediatrician offices, police, teachers and other school personnel, and various state agencies including child-protective services. Any of these may provide immediate evaluations, possible short-term housing, counseling services for parents and children, foster-home placements, and adoption as needed.
3. There are various treatment options to be considered. Medicines may be indicated but victims of abuse often do not respond to the usual medicines, possibly due to a distinct biological endophenotype . In any case, polypharmacy is to be avoided.
There are also various counseling approaches that are supported by databases and that have proved helpful. These include Abuse-Focused Cognitive Behavioral Therapy and Parent-Child Interactive Therapy . Therapists need to be aware that there may be court-ordered contracts for safety that they are expected to monitor and evaluate.
4. Continuous work with child-abuse victims and their families may be taxing for professionals in any discipline. Professionals should seek individual supervision or peer supervision and avail themselves of patient-at-risk consultations. Providers should also practice self-care and obtain post-incident crisis counseling for any major event that occurs .
1. Schilling, S., and Christian, C. W. (2014). “Child Physical Abuse and Neglect.” Child and Adolescent Psychiatric Clinics of North America, 23: 309-19.
2. Zeamah, C. H., and Humphreys, K. L. (2018). “Child Abuse and Neglect.” Journal of the American Academy of Child & Adolescent Psychiatry, 57:637-44.
3. Flannery, R. B. Jr. (2012) Posttraumatic Stress Disorder: The Victim’s Guide to Healing and Recovery.Second Edition. Riverdale, NY: American Mental Health Foundation.
4. Nemeroff, C. B. (2016). “Paradise Lost: The Neurobiological and Clinical Consequences of Child Abuse and Neglect.” Neuron, 89: March 2.
5. Widom, C. S. (1989). “Does Violence Beget Violence?” A Critical Examination of the Literature.” Psychological Bulletin, 106: 3-28.
6. Flannery, R. B. Jr. (2009). The Violent Person: Professional Risk Management Strategies for Safety and Care. Riverdale, NY: American Mental Health Foundation.
Raymond B. Flannery Jr., Ph.D., FACLP, a licensed clinical psychologist, is Associate Professor of Psychology (Part Time), Department of Psychiatry, Harvard Medical School, as well as Adjunct Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School and Adjunct Professor of Psychology (Part-Time), the Woods College of Advancing Studies, Boston College. He is an internationally recognized and award-winning scholar and lecturer on the topics of violence, victimization, and stress management. Dr. Flannery is available for lectures and workshops, for all types and sizes of groups, and may be reached at The American Mental Health Foundation.