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Child abuse and neglect

© 2003 The Center for Pediatric Emergency Medicine of the New York University School of
Medicine
Readers are encouraged to duplicate and use all or part of the information contained in this
publication for educational purposes only. In accordance with accepted publishing standards,
permission must be obtained from the Center for Pediatric Emergency Medicine for information
reproduced in another publication.
Illustrations created by Virginia Ferrante, MA. All drawings and text may be reproduced, as they
appear, for not-for-profit use to educate medical personnel.
Cite as: David Markenson, Michael G. Tunik, Marsha Treiber, Arthur Cooper, Andrew
Skomorowsky, George L. Foltin. Child Abuse and Neglect: A Prehospital Continuing Education
and Teaching Resource. New York, NY: Center for Pediatric Emergency Medicine, 2003.
The mission of the Center for Pediatric Emergency Medicine (CPEM) is to improve emergency
medical services for children in the United States through education, research, advocacy, and
systems development. Established in 1985 at New York University School of Medicine and
Bellevue Hospital Center in New York City, CPEM is funded primarily by the US Department of
Health and Human Services/Health Resources and Services Administration through its Maternal
and Child Health Bureau, EMSC Program.
The recommendations in this publication are not intended to
indicate an exclusive course of treatment or to serve as a
standard of medical care. Individual circumstances may require
variations on these recommendations. CPEM disclaims any

liability or responsibility for the consequences of any action
taken in reliance on the statements or opinions contained herein.


Published by
Center for Pediatric Emergency Medicine
Bellevue Hospital Center, Room 1 East 9
27th Street & First Avenue
New York, New York 10016
212/562-4470
212/562-7753 fax
www.cpem.org
This manual was supported by project grant 4 H34 MC 00077 from the Emergency Medical Services for Children Program as provided by Section 1910 of
the US Public Health Service Act. Emergency Medical Services for Children is administered by Maternal and Child Health Bureau, Health Resources and
Services Administration, Public Health Service, US Department of Health and Human Services in cooperation with the National Highway Traffic Safety
Administration.

Editors:
David S. Markenson, MD, FAAP, EMT-P
Mailman School of Public Health, Columbia University
Michael G. Tunik, MD, FAAP
New York University School of Medicine
Marsha Treiber, MPS
New York University School of Medicine
Arthur Cooper, MD, FAAP, FACS
Columbia University College of Physicians and Surgeons
Andrew Skomorowsky, MFA, NREMT-P
New York University School of Medicine
George L. Foltin, MD, FAAP, FACEP
New York University School of Medicine

Executive Editor: Susan E. Aiello, DVM, ELS
Contributors:
Raphael M. Barishansky, MPH, Hudson Valley Regional EMS Council
Kathleen Brown, MD, Emergency Department of Children’s National Medical Center
Linda Cahill, MD, Child Protection Center of Montefiore Medical Center
Karen M. Caravaglia, MS, EMT-P, National Center for Disaster Preparedness,
Columbia University Mailman School of Public Health
Lynn Babcock Cimpello, MD, Departments of Emergency Medicine and Pediatrics
University of Rochester School of Medicine and Dentistry

Susan McDaniel Hohenhaus, RN, BS, EMSC at Duke University Health System
Lori Legano, MD, Child Protection and Development Center of Bellevue Hospital
Hedda Matza-Haughton, MSW, CSW, “For the Health of It” Consultation Services
Margaret McHugh, MD, MPH, Child Protection and Development Center of Bellevue Hospital
Jeffrey Meade, NREMT-P, CIC, Emergency Life Support Programs of
Phelps Memorial Hospital Center
LaVoyce Reid, MSW, LCSW, National Association of Social Workers
Laura L. Rogers, JD, American Prosecutors Research Institute’s
National Center for Prosecution of Child Abuse

Medical Illustrator: Virginia Ferrante, MA
Executive Producer - CD-ROM: Mark Marshall
Programming/Mastering/Package Design: Maximum Interactive
www.maximuminteractive.com


If you have any questions regarding the use or contents of this resource, please contact CPEM (click here to connect)

CHILD ABUSE AND NEGLECT
TABLE OF CONTENTS

Foreword…………………………………………………………………………………...i
Introduction
Chapter Objectives.................................................................................................... 1
Background............................................................................................................... 1
Risk Factors .............................................................................................................. 1
Child Risk Factors ............................................................................................... 2
Parental Risk Factors ........................................................................................... 2
Societal Risk Factors ........................................................................................... 2
Cycle of Abuse… ................................................................................................ 2
Role of Pre-Hospital Medical Providers..................................................................... 3
Reporting Requirements ............................................................................................ 3
Handout ................................................................................................................... 4
Definitions
Chapter Objectives.................................................................................................... 5
Abuse and Neglect Defined ....................................................................................... 5
The Child Abuse Prevention and Treatment Act .................................................. 5
Mandated Reporters .................................................................................................. 6
The Abused Child, Abusive Actions, and the Abuser................................................. 6
Child Maltreatment ................................................................................................... 7
Types of Child Abuse................................................................................................ 7
Physical Abuse .................................................................................................... 7
Sexual Abuse....................................................................................................... 7
Emotional Abuse ................................................................................................. 7
Neglect ................................................................................................................ 7
Case Scenario ........................................................................................................... 8
Handout ................................................................................................................... 9
Recognition
Chapter Objectives.................................................................................................. 10
Importance of the History........................................................................................ 10
Recognizing the Mechanism and Patterns of Injury ................................................. 11
Early Childhood Development........................................................................... 11
Right to Privacy ...................................................................................................... 12
Physical Abuse........................................................................................................ 12
Skin Injuries ...................................................................................................... 12
Bruises......................................................................................................... 12
Burns ........................................................................................................... 13
Adult Human Bites ...................................................................................... 13
Fractures............................................................................................................ 13


Falls .................................................................................................................. 14
Injuries to the Face and Head............................................................................. 14
Hair Loss........................................................................................................... 14
Shaken Baby Syndrome..................................................................................... 14
Sexual Abuse .......................................................................................................... 15
Emotional Abuse..................................................................................................... 15
Neglect.................................................................................................................... 16
Munchausen Syndrome by Proxy ............................................................................ 16
Sudden Infant Death Syndrome ............................................................................... 17
Cultural Considerations ........................................................................................... 18
Case Scenarios........................................................................................................ 19
Handout ................................................................................................................. 20
High-Risk Families and Situations
Chapter Objectives.................................................................................................. 22
Differentiating High-Risk Families and Situations................................................... 22
Role of Prehospital Medical Providers..................................................................... 23
Surveying the Scene .......................................................................................... 23
Challenges and Strengths of EMS Providers ...................................................... 24
Intervention ....................................................................................................... 24
Case Scenario ......................................................................................................... 25
Handout ................................................................................................................. 26
Reporting
Chapter Objectives.................................................................................................. 27
State Law ................................................................................................................ 27
Consequences of Failing to Report .......................................................................... 28
Form of Report........................................................................................................ 28
Content of Report.................................................................................................... 29
Communicating with Caregivers ............................................................................. 29
Transfer of Care ...................................................................................................... 30
National Child Abuse Hotline and State Reporting Numbers ................................... 30
Case Scenario ......................................................................................................... 32
Handout ................................................................................................................. 33
Documentation
Chapter Objectives.................................................................................................. 36
Evidence ................................................................................................................. 36
Importance of Documentation ................................................................................. 37
Proper Documentation............................................................................................. 37
General Principles ............................................................................................. 37
Documenting the Scene ..................................................................................... 38
Documenting the History................................................................................... 38
Documenting the Reasons for Suspicion and Actions Taken.............................. 39
Victim other than the Specified Patient .............................................................. 40
Case Scenario ......................................................................................................... 40


Handout ................................................................................................................. 41
Child Protection Services
Chapter Objectives.................................................................................................. 43
Function of CPS ...................................................................................................... 43
Process of the CPS Agency ..................................................................................... 43
Sample Case Flow................................................................................................... 44
Further Role of EMS Providers ............................................................................... 44
Handout ................................................................................................................. 45
Medicolegal Issues
Chapter Objectives.................................................................................................. 46
Introduction and Overview ...................................................................................... 46
Hearsay Exceptions ................................................................................................. 47
Excited Utterance .............................................................................................. 47
State of Mind..................................................................................................... 47
Statement Made for Medical Diagnosis ............................................................. 47
Present Sense Impression................................................................................... 48
Catch-all Exception ........................................................................................... 48
Totality of the Circumstances ............................................................................ 48
Report Writing and Evidence Collection.................................................................. 49
Verbatim Statements.......................................................................................... 49
Demeanor and Emotions.................................................................................... 49
Timing............................................................................................................... 49
Evidence Collection........................................................................................... 49
Mandatory Reporting .............................................................................................. 51
Hearsay and EMS Providers (Expanded Explanatory Text) ..................................... 52
Handout ................................................................................................................. 63
Illustrations
Figure 1 – Accidental Bruising ................................................................................ 66
Figure 2 – Inflicted Burns and Pinch and Slap Marks .............................................. 67
Figure 3 – Inflicted Burns........................................................................................ 68
Figure 4 – Accidental Splash Burns......................................................................... 69
Figure 5 – Cord and Belt Marks and Inflicted Burns................................................ 70
Figure 6 – Coining and Cupping.............................................................................. 71
Images
Image A – Slap Mark, Face ..................................................................................... 72
Image B – Grab Marks, Arm ................................................................................... 73
Image C – Accidental Bruising, Shins ..................................................................... 74
Image D – Immersion Burns, Hands........................................................................ 75
Image E – Immersion Burns, Feet............................................................................ 76
Image F – Immersion Burns, Buttocks..................................................................... 77
Image G – Hot Liquid Burn, Face and Chest ........................................................... 78


Image H – Coin Rubbing......................................................................................... 79
Image I – Cupping................................................................................................... 80
Image J – Looped Cord Marks................................................................................. 81
Image K – Strangulation Marks ............................................................................... 82


i

CHILD ABUSE AND NEGLECT
FOREWORD

What do emergency medical services (EMS) providers know about child abuse and neglect?
This question was the focal point of a three-year grant project undertaken by the Center for
Pediatric Emergency Medicine (CPEM) and funded by the EMS for Children (EMSC)
Program of the federal Health Resources Services Administration (HRSA)/Maternal and
Child Health Bureau (MCHB).
The goals of the National Child Protection Education Project included the following:






assess current understanding of the recognition, reporting, and prevention of child
abuse and neglect; treatment of its victims; and the attitudes toward this distressing
problem among the nation’s prehospital medical providers
analyze the results
bring EMS, EMSC, and child protection advocates together to evaluate results
utilize the findings to develop this educational program

Three million cases of child abuse are reported in the US annually, making this a significant
public health care concern. EMS providers are in a unique position, often being the only
individuals who have access to a patient’s home. They can be the “eyes and ears” of the
medical community. Their ability to assess and deal sensitively with this issue can have a
positive impact on the morbidity and mortality of children. While there is a vast amount of
information on managing child maltreatment for many levels of health care providers, there
has been little information regarding the role of EMS providers. Furthermore, there has been
no information on the knowledge, attitude, and state of readiness of EMS providers to deal
with child maltreatment. The result was a lack of uniform national resource material
addressing the educational needs, attitudes, and role of EMS and other prehospital providers
in child protection. CPEM has addressed this gap.
First, a national coalition of experts in EMS, EMSC, and child protection was formed. This
group, along with input of the National EMSC Data Analysis Research Center, created,
piloted, and refined a survey questionnaire in collaboration with the National Registry of
EMTs and 15 State EMS Directors. In concert with this survey, courses and curricula
currently in existence on child abuse and neglect were identified. Although there were many
courses and curricula for other professionals, such as police, social workers, and nurses,
virtually nothing existed specifically for the prehospital provider. In addition, information
concerning statewide regulations on child abuse in all 50 states was compiled.

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Second, EMS providers throughout the nation, at the EMT-Basic, EMT-Intermediate, and
EMT-Paramedic levels, were assessed regarding their knowledge of the following:






the definitions of child abuse and neglect
possible signs and symptoms of child abuse or neglect
treatment and transportation strategies
proper documentation and reporting
child abuse and neglect laws, regulations, and agency policies in their area of
operation

A key aspect of the project was to evaluate and consider the self-efficacy and attitudes of
prehospital providers toward recognition and management of child abuse and neglect.
Following these efforts, a Blue Ribbon panel of national experts in EMSC and child
protection met in October of 2001 to review the results of these surveys and to make
recommendations on content for the EMS child protection resource. (Proceedings can be
found on the CPEM website, www.cpem.org, under “Resources.”)
The final result, Child Abuse and Neglect: A Continuing Education and Teaching Resource
for the Prehospital Provider, was created specifically for instructors of EMS prehospital
providers. A review board of national experts in EMS, EMSC, and child protection reviewed
draft sections of this educational resource, and national and regional workshops were held to
gather the input of the EMS instructors themselves.
CPEM is gratified by the continuing confidence shown in us by the federal government in the
funding of our efforts to improve EMSC around the country. We are thankful for the
enormous amount of enthusiasm generated by this exciting project. We are grateful for the
wonderful letters of support from EMS, pediatric and child protection organizations, and
especially the State EMS Directors who have consistently supported our efforts.
ACKNOWLEDGMENTS

We would like to acknowledge those individuals whose contribution to the development of
this resource was invaluable. We thank Dr. David Heppel, Dan Kavanaugh, MSW, Cindy
Doyle, RN, and Mickey Reynolds of the HRSA/MCHB EMSC Program, for their direction
and assistance with this project; thanks also to that agency as a whole for providing financial
support. We express our appreciation to Lenora Olson, MA and Lawrence Cook, MStat, from
the National Data Analysis Research Center (NEDARC), and to William R. Brown, Jr.,
NREMT-P, and Philip Dickison, NREMT-P, of the National Registry of EMTs (NREMT) for
assistance in the design and distribution of the assessment questionnaire, and in the
subsequent data collection, management, and analysis of the results.

Foreword

Child Abuse and Neglect


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The authors would especially like to thank Hedda Matza-Haughton, MSW, CSW, for her
professional and enthusiastic management of the project in the establishment of the advisory
board and expert review panel, in the development of the assessment questionnaire and its
distribution, and in the coordination of the Blue Ribbon panel consensus meeting. Sarah
Gagnon, EMT, also provided capable and efficient administrative assistance during the
developmental stages of the project.
We would like to thank Jane Ball, RN, MPH, DrPH, Ken Allen, Yvonnada Cousins, and the
staff of the EMSC National Resource Center, who helped to coordinate the consensus
meeting, as well as those who attended and provided invaluable input.
This program was piloted, with the skilled assistance of Karen Caravaglia, MSOL, EMT-P, at
the New York State Vital Signs Conference (coordinated by Donna Gerard), the Alaska State
EMS Conference (coordinated by Doreen Risley), and at a special workshop hosted by
Oklahoma City EMSC at the University of Oklahoma (coordinated by Paul Marmen). We are
extremely grateful for their gracious hospitality and for the individuals in the workshops who
provided essential feedback about our program.
We would like to thank Dr. Margaret McHugh and Dr. Lori Legano of the Child Protection
and Development Center of Bellevue Hospital, whose consistent support and expertise greatly
strengthened this resource.
Many national organizations provided representation on our advisory board, including the
following: American Academy of Pediatrics (AAP), American Academy of Child and
Adolescent Psychiatry, American College of Emergency Physicians, Ambulatory Pediatric
Association, American Psychological Association, Child Welfare Institute, Emergency Nurses
Association, International Association of Chiefs of Police, International Association of Fire
Chiefs, International Society for the Prevention of Child Abuse and Neglect, National
Alliance of Children’s Trust and Prevention Funds, National Association of Emergency
Medical Services Educators, National Association of Emergency Medical Services
Physicians, National Association of Emergency Medical Technicians, National Association of
Pediatric Nurse Practitioners, National Association of School Nurses, National Association of
Social Workers, National Association of State Emergency Medical Services Directors,
National Children’s Alliance, National Center for Prosecution of Child Abuse, National
Council of State Emergency Medical Services Training Coordinators, National EMSC Data
Analysis Resource Center, National Registry of Emergency Medical Technicians, and Prevent
Child Abuse America. Their participation and continued support are deeply appreciated.
We would like to thank the AAP for their gracious permission to use the color images
included on the CD version of this resource from their publication The Visual Diagnosis of
Child Physical Abuse, 1994.
We are grateful to Senator Daniel K. Inouye of Hawaii; to his dedicated administrative
assistant, Dr. Patrick DeLeon; and to Senator Orrin G. Hatch of Utah for creating the EMSC
National Funding Initiative; and to those individuals who work diligently to upgrade
emergency medical services for children in the United States.

Foreword

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Finally, we are extremely grateful to the numerous paramedic instructors, medical experts,
and educational consultants who carefully critiqued the information to ensure that this
resource would be both relevant and appropriate. Many more dedicated professionals than we
could possibly name gave generously of their own time and expertise. Their enthusiastic
participation has been a motivating force behind this project, and they received no
compensation beyond the knowledge that they were helping to create a greatly needed
resource. We hope the final product lives up to their efforts, hopes, and expectations.
George L. Foltin, MD, FAAP, FACEP
Director
Center for Pediatric Emergency Medicine
www.cpem.org

Foreword

Child Abuse and Neglect


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CHILD ABUSE AND NEGLECT
INTRODUCTION

CHAPTER OBJECTIVES
• Create awareness of prevalence of child abuse and neglect
• Identify various risk factors for child abuse and neglect
• Emphasize unique role and contributions of prehospital medical providers in
recognizing and reporting child abuse and neglect
• Introduce legal aspects of reporting child abuse and neglect

BACKGROUND
Child abuse and neglect is found across all levels of socioeconomic status, all racial and
ethnic (cultural) groups, and all religious affiliations. Abuse and neglect is widespread
and found in every type of household. All EMS providers will likely see cases of child
abuse or neglect at some time.
Child abuse is far more prevalent in the United States than many people think. The
combined incidence of abuse and neglect is estimated to be about 3 million cases per
year, or about 12 cases for every thousand children (US Department of Health and Human
Services. Child Maltreatment 1996: reports from the States to the National Child Abuse and Neglect Data
System, Washington DC: U.S. Government Printing Office, 1998). Several thousand children die

each year from acts of child abuse. Many cases are never reported, so the actual figures
are certainly much higher. In addition, many more children who are assumed to have
died of illness or accidental injury may have suffered abuse as a contributing factor.
KEY POINT:

Child abuse and neglect is found across all levels of socioeconomic status,
all racial and ethnic (cultural) groups, and all religious affiliations.

KEY POINT:

All EMS providers will likely see cases of child abuse or neglect at some
time.

Dr. C. Henry Kempe is considered to be the “father” of the study of child abuse and
neglect. Although it’s tempting to believe that parents who abuse their children don’t
love them, Kempe’s work showed that this generally is not true. Often, these adults treat
their children as their parents treated them; in other words, they do not know how to treat
their children appropriately or how to be effective parents. Although seeing these types
of cases can generate a lot of emotion, it is important to remember that most of these
parents “love their children very much but not very well.”

RISK FACTORS AND THE CYCLE OF ABUSE
As mentioned above, child abuse or neglect is found in every type of household and is
not restricted to any economic, racial, or cultural segment of society. However, there are
certain conditions that can make children more vulnerable to becoming a victim of abuse.

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These risk factors can result from the characteristics of the child or the parent, or from the
influences of today’s society.
Child Risk Factors
Some children are unable to meet their parents’ expectations simply because of their age
(usually younger than 4 years old), or if they have congenital anomalies or a chronic
illness. Even when parents’ expectations are realistic and age-appropriate, children who
for any reason experience slow development or a developmental delay may not be able to
meet these expectations. Hence, the child may be perceived as “different” or “abnormal”
and possibly more vulnerable to abuse. These children often require additional care,
time, and resources, which can all place additional burdens on an already stressed parent
or family.
Parental Risk Factors
Parents sometimes have unrealistic expectations of their child’s development or behavior.
For example, it is unrealistic for parents to expect a one-year-old child to be toilettrained. Parents who were abused when they were children and who haven’t learned how
to deal with stress, frustration, or anger might be more likely to abuse their own children.
Substance abuse is also a risk factor, as is isolation. When families are isolated or isolate
themselves, they often do not develop support systems, do not know how to identify and
use social support systems, and do not trust others.
Societal Risk Factors
Risk factors imposed by society include various types of violence, as well as poverty and
a lack of access to health care and other services. The rate of child abuse is far higher in
homes in which there is domestic violence and the mother is also abused. Exposure to
violence on television has also been related to an increased acceptance of aggressive
attitudes and behavior.
The Cycle of Abuse
Family violence is associated with an increased likelihood of child abuse. Children who
have been abused often learn in turn to be more aggressive toward other more vulnerable
family members. In this way, abuse is perpetuated into the next generation, resulting in
the “abused-to-abuser” cycle.
To prevent abuse from continuing, the cycle must be interrupted. Ways to assist in doing
so include:
• obtaining greater assistance from local child protection agencies (eg, parenting
information and classes)
• providing counseling and support for all family members
• involving the child with a nonabusive adult
Having family resources available to EMS providers may help the referral system in a
community.

Introduction

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ROLE OF PREHOSPITAL MEDICAL PROVIDERS
EMS providers are in a unique position of being able to recognize and report suspected
child abuse and neglect. This important role is based on a number of factors. EMS
providers are:
• often the only health care professionals who have unannounced access to a
patient’s home
• able to assess the family environment and relationships among family members
• often first on the scene of an emergency
• first to gather the history in a situation that is suspicious of abuse or neglect
Accordingly, EMS providers also have a great responsibility to recognize and report
suspected child abuse and neglect to help safeguard children. To fulfill this important
role, EMS providers must be able to:
• recognize the signs and symptoms of abuse or neglect
• provide immediate medical evaluation and treatment
• protect the child from further abuse
• document all findings accurately, thoroughly, and legibly
• report all cases of suspected abuse and neglect
KEY POINT:

EMS providers are society’s first defense against child abuse and neglect.
They can be the eyes and ears of the medical community.

REPORTING REQUIREMENTS
States differ in their laws regarding the reporting of suspected child abuse or neglect, and
all EMS providers should become familiar with the laws in their state. In most states,
EMS providers are legally required to report such suspicions to the appropriate
authorities. For example, in the state of New York, all EMS providers are mandated
reporters and, therefore, are required to report information concerning suspected child
abuse provided such information was attained in the performance of their official duties.
Furthermore, there are penalties associated with failing to report a case of suspected child
abuse or neglect. However, in all states, the law provides for immunity from liability, as
long as the report was made in “good faith” with no malicious intent. In addition to the
legal obligation to report, everyone has a moral obligation to report suspected child abuse
or neglect to prevent it from continuing. (For more information on reporting, see also the
chapters on Reporting and Medicolegal Issues.)

Introduction

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Handout

4

CHILD ABUSE AND NEGLECT
INTRODUCTION

Background
Child abuse and neglect is widespread and found across all levels of socioeconomic
status, all racial and ethnic (cultural) groups, and all religious affiliations.
All EMS providers will likely see cases of child abuse or neglect at some time.
EMS providers are society’s first defense against child abuse and neglect. They can be
the eyes and ears of the medical community.
Risk Factors
Risk factors can make children more vulnerable to becoming a victim of child abuse or
neglect. Risk factors can result from the characteristics of the child (eg, delayed
development, chronic illness) or of the parent (eg, unrealistic expectations, substance
abuse, isolation), or from the influence of today’s society (eg, violence, poverty).
Role of Prehospital Medical Providers
Prehospital medical providers are in a unique position to recognize and report suspected
child abuse or neglect. They are:
• Often the only health care professionals permitted access to a patient’s home
• Able to assess family environment and relationships among family members
• Often first on the scene
• First to gather history
Prehospital medical providers also have a great responsibility in suspected cases of child
abuse or neglect. They must be able to:
• Recognize signs and symptoms of abuse or neglect
• Provide medical evaluation and treatment
• Protect from further abuse
• Document all findings accurately, thoroughly, and legibly
• Report all cases of suspected abuse or neglect
Reporting Requirements
Reporting requirements vary by state. In most states, EMS providers are mandated
reporters, ie, legally required to report suspected child abuse or neglect. All states
provide mandated reporters with immunity from liability provided the report was made in
“good faith” with no malicious intent. Everyone has a moral obligation to report.

©2003. Center for Pediatric Emergency Medicine. Permission is granted to copy this material for educational purposes only.

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CHILD ABUSE AND NEGLECT
DEFINITIONS

CHAPTER OBJECTIVES
• Define child abuse and neglect
• Define mandated reporters
• Explain the legal definition of child maltreatment
• Define and explain physical abuse, sexual abuse, emotional abuse, and neglect
• Present and discuss case scenario

ABUSE AND NEGLECT DEFINED
The following are general definitions of child abuse and neglect:
In child abuse, a child has suffered physical and/or emotional injury inflicted by a
caregiver (eg, parent, legal guardian, teacher, etc) that results in disability, disfigurement,
mental distress, or risk of death.
In child neglect, a child’s physical, mental, and/or emotional condition has been
endangered because the caregiver has not provided for the child’s basic needs.
However, states vary in their definition of child abuse and neglect and in their efforts to
regulate protective services for children. For example, some states emphasize the
presence of serious physical injury to substantiate a finding of physical abuse or neglect,
while other states emphasize simply the presence of an imminent threat of injury. When
in doubt, prehospital medical providers should always err on the side of caution and
either consult with child protection services or make a referral.
The Child Abuse Prevention and Treatment Act
A widely accepted definition of child abuse and neglect is provided by the federal Child
Abuse Prevention and Treatment Act (PL 93-247) enacted in 1974, as amended by the
Child Abuse Prevention, Adoption, and Family Services Act of 1988 and by the Keeping
Children and Families Safe Act of 2003.
The Act defines child abuse and neglect as:
“the physical or mental injury, sexual abuse or exploitation, negligent treatment,
or maltreatment of a child under the age of 18, or except in the case of sexual
abuse, the age specified by the child protection law of the State by a person
(including any employee of a residential facility or any staff person providing outof-home care) who is responsible for the child's welfare under circumstances
which indicate that the child’s health or welfare is harmed or threatened
thereby...”

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The Act defines sexual abuse as:
“the use, persuasion, or coercion of any child to engage in any sexually explicit
conduct (or any simulation of such conduct) for the purpose of producing any
visual depiction of such conduct, or rape, molestation, prostitution, or incest with
children...”
Amendments to the Child Abuse Prevention and Treatment Act also include as child
abuse the withholding of medically indicated treatment for an infant’s life-threatening
condition(s).

MANDATED REPORTERS
Mandated reporters are professionals designated by state law because they are
specifically equipped to recognize child maltreatment, abuse, or neglect. In addition, by
virtue of their position and role in society, they are opportune personnel to recognize
child maltreatment, abuse, or neglect. Mandated reporters are legally required to report
suspected child abuse or neglect when presented with reasonable cause. Examples of
individuals who are mandated reporters in all or most states include EMS providers,
physicians, nurses, teachers, police, lawyers, counselors, and others. (For more
information on reporting, see also the chapters on Reporting and Medicolegal Issues.)
KEY POINT:

Mandated reporters are legally required to report suspected child abuse or
neglect when presented with reasonable cause. EMS providers are
mandated reporters in most states.

THE ABUSED CHILD, ABUSIVE ACTIONS, AND THE ABUSER
An abused child is a child less than 18 years old whose parent or other person legally
responsible for his or her care, inflicts, or allows to be inflicted on the child, serious
physical injury, a substantial risk of physical injury, or a sexual offense against the child.
Abusive actions against a child include serious physical injury that is not explained by the
history and cannot have been caused accidentally, any act of a sexual nature on or with a
child, or chronic attitude or acts that interfere with the healthy psychological or social
development of a child.
Close to 90% of the perpetrators of child maltreatment are the parents, a parent’s
paramour, or other relatives. The rest are persons in other caretaking roles (eg, foster
parents, facility staff, child care providers).

Definitions

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CHILD MALTREATMENT
A maltreated child is a child less than 18 years old whose physical, mental, and/or
emotional condition has been impaired or is in danger of becoming impaired as a result of
the failure of his or her parent or other person legally responsible for his or her care to
exercise a minimal degree of care. This includes the following:
• failure to supply the child with adequate food, clothing, shelter, education, or
medical or surgical care, although financially able to do so or offered financial or
other reasonable means to do so
• failure to provide the child with proper supervision or guardianship
• unreasonably inflicting, or allowing to be inflicted, harm or substantial risk
thereof, including the infliction of excessive corporal punishment
• using a drug or drugs
• using alcoholic beverages to the extent that he or she loses self control of his or
her actions
• any other acts of a similarly serious nature requiring the aid of the family court

TYPES OF CHILD ABUSE
The four types of child abuse are physical abuse, sexual abuse, emotional abuse, and
neglect, with the latter being the most common.
Physical Abuse
In physical abuse, a nonaccidental physical injury that results in distress, disfigurement,
or death is inflicted on a child. Examples of physical abuse include punching, beating,
kicking, biting, burning, and shaking. The use of physical discipline is also included if it
leaves a lasting physical mark.
Sexual Abuse
Sexual abuse consists of using, persuading, or coercing a child to engage in any sexually
explicit conduct. Examples include fondling, intercourse (including incest), rape,
molestation, sodomy, and exhibitionism. Forcing a child to view pornography is also
considered sexual abuse.
Emotional Abuse
In emotional abuse, the parent or caregiver exhibits persistent behavior that interferes
with the normal development of a child. Emotional abuse is present in all other forms of
child abuse, but it can also be seen by itself.
Neglect
Neglect is the most common form of abuse. It is failure to act on behalf of a child and
includes the following:
• Failure to provide for the child’s physical, mental, or emotional needs
• Failure to provide adequate food, clothing, shelter, education, or medical care,
including a delay in seeking care for a known illness
• Failure to meet requirements basic to a child’s physical development

Definitions

Child Abuse and Neglect

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8






Failure to provide support or affection necessary to a child’s psychological and
social development
Failure to provide proper supervision
Abandonment
Substance abuse (excessive use of drugs or alcohol) by the parent or caregiver
such that it interferes with his or her ability to supervise the child

KEY POINT:

The four types of child abuse are physical abuse, sexual abuse, emotional
abuse, and neglect. Emotional abuse is present in all other forms of child
abuse but can also be seen by itself. Neglect is the most common form of
child abuse.

CASE SCENARIO
Discuss the following case scenario and whether child abuse or neglect should be
suspected.
Case: On arriving at an emergency call, EMS providers find a 2-year-old girl sitting on
the couch in the living room with her mother and aunt. The child has her feet up and a
bag of ice on her lower left leg. The mother says that the girl fell off a chair in the living
room while trying to reach a jar on a high shelf. On examining the child, there is a
greenish yellow bruise surrounding her upper right arm and a long, rectangular, reddish
purple bruise across the child’s back. The mother offers no explanation for these bruises.
The ankle under the ice bag is swollen, bruised, and tender. The aunt says the child fell
off the parents’ bed and hurt her leg. When the EMS providers ask the girl how she hurt
her leg, the girl becomes upset and starts to cry. No shelves are seen in the living room,
and the floor is carpeted.

Definitions

Child Abuse and Neglect

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Handout

9

CHILD ABUSE AND NEGLECT
DEFINITIONS

General Definitions
In child abuse, a child has suffered physical or emotional injury inflicted by a caregiver
(eg, parent, legal guardian, teacher, etc) that results in disability, disfigurement, mental
distress, or risk of death. In child neglect, a child’s physical, mental, or emotional
condition has been endangered because the caregiver has not provided for the child’s
basic needs.
Note: States vary in their definition of child abuse and neglect and in their efforts to
regulate protective services for children. When in doubt, prehospital medical providers
should always err on the side of caution.
KEY POINT:

Mandated reporters are legally required to report suspected child abuse or
neglect when presented with reasonable cause. EMS providers are
mandated reporters in most states.

Types of Abuse
In physical abuse, an inflicted physical injury results in distress, disfigurement, or death
of a child (eg, punching, beating, kicking, biting, burning, shaking).
Sexual abuse consists of using, persuading, or coercing a child to engage in any sexually
explicit conduct (eg, fondling, intercourse, rape, molestation, sodomy, exhibitionism).
In emotional abuse, the parent or caregiver exhibits persistent behavior that interferes
with the normal development of a child. Emotional abuse is present in all other forms of
child abuse, but it can also occur by itself.
Neglect is the most common form of abuse. It is failure to act on behalf of a child and
includes the following:
• Failure to provide for the child’s physical, mental, or emotional needs
• Failure to provide adequate food, clothing, shelter, education, or medical care,
including a delay in seeking care for a known illness (eg, a baby’s diaper changed
so infrequently that a severe, red, scaly diaper rash develops)
• Failure to meet requirements basic to a child’s physical development
• Failure to provide support or affection necessary to a child’s psychological and
social development
• Failure to provide proper supervision
• Abandonment
• Substance abuse (excessive use of drugs or alcohol) by the parent or caregiver
such that it interferes with his or her ability to supervise the child
KEY POINT:

The four types of child abuse are physical abuse, sexual abuse, emotional
abuse, and neglect. Emotional abuse is present in all other forms of child
abuse but can also be seen by itself. Neglect is the most common form of
child abuse.

©2003. Center for Pediatric Emergency Medicine. Permission is granted to copy this material for educational purposes only.

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10

CHILD ABUSE AND NEGLECT
RECOGNITION

CHAPTER OBJECTIVES
• Emphasize the importance of the history in relation to the extent of injury in
recognizing the possibility of child abuse
• Recognize patterns of injury in child abuse to differentiate between unintentional
and inflicted injuries
• Develop familiarity with normal childhood developmental abilities
• Review typical injuries commonly seen in physical abuse of children, including
skin injuries, fractures, falls, injuries to the face and head, hair loss, and shaken
baby syndrome
• Review typical presentation of cases of sexual abuse in children and how to
appropriately manage such cases
• Review characteristics of emotional abuse in children
• Review specific indicators of neglect
• Create awareness of cultural differences and the impact they have on evaluation
of suspected child abuse
• Explain recognition and management of cases of sudden infant death syndrome
• Present and discuss case scenarios

IMPORTANCE OF THE HISTORY
To recognize abuse, abuse must be considered a possibility. Errors in recognizing child
abuse can have devastating consequences; the child, and possibly other children in the
household, may suffer needlessly.
Determining whether an injury or illness could have been caused unintentionally or was
inflicted is critical. In general, people want and tend to believe what they are told.
Therefore, considering whether the injury or illness is consistent with the history given by
the parent or caregiver and by the child is extremely important. For example, if a parent
says a child fell off the couch and struck her head on the floor, but the floor is carpeted
and the child is limp and unresponsive, the extent of injury is inconsistent with the
history. Likewise, when the parent or caregiver says “I don’t know what happened,” or
“It was an accident,” or the explanation given is vague, further investigation is warranted.
Other historical factors that might indicate the presence of abuse include multiple visits to
the same household, inadequately explained incidents, or previous visits to the household
for family violence. Noting this information may indicate a more in-depth evaluation,
especially when multiple health care providers are involved.
KEY POINT:

Always consider whether the history is consistent with the injury. If the
history is not consistent with the severity of the injury, abuse must be
strongly considered.

Center for Pediatric Emergency Medicine

Child Abuse and Neglect

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11

RECOGNIZING THE MECHANISM AND PATTERNS OF INJURY
One of the most important areas of expertise for the EMS provider is the interpretation of
mechanism of injury. This must be considered in view of the history, again noting
whether or not the injuries are consistent with the history.
Early Childhood Development
When trying to identify the mechanism of an injury in a child, it is important to consider
the child’s developmental age. For an injury to occur unintentionally, the child must be
developmentally mature enough to have caused the specific injury, ie, the child must
have specific motor skills. For example, an explanation of a 6-week-old infant crawling
into a hazardous area raises suspicion because such a young child is not physically or
developmentally able to crawl. Likewise, if the explanation is that a sibling caused the
injury, whether the sibling is developmentally capable of doing so must be considered.
The following table provides some general guidelines for developmental abilities in early
childhood.
Age

Developmental Abilities

Birth–1 month

Normally alert, looking around
Focuses on faces or objects, but does not follow movement
Extremities flexed at elbows and knees
2–3 months
Follows movement of objects or faces
Begins to smile
Extremities flexed at elbows and knees
4–6 months
Begins to eat baby food with assistance
Reaches for objects
4–10 months
Crawls
Rolls over
May grab at objects or push away hand(s) of others
Extremity flexion decreases
6–8 months
Can sit up
Becomes fearful of strangers
Begins imitating word sounds (eg, ma ma ma, da da da)
12 months
Stands
12-18 months
Learns to walk
Can climb stairs one step at a time (18 months)
Begins to use single words
2 years
Actively explores environment
Does not like to sit still (understatement)
3 years and older
Develops language and some reasoning abilities
Note: Children who are frightened or in pain may act younger than their age.

Recognition

Child Abuse and Neglect

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12

RIGHT TO PRIVACY
Children have the right to privacy and can refuse to have their privacy invaded.
Adolescents are often especially sensitive about privacy issues. An unwilling child
should never be examined, especially if the child is suspected to be a victim of sexual
abuse. In these cases, the EMS provider could be perceived as part of the assault.
Certainly, there are times when a child needs care and doesn’t like it. Explanations can
sometimes help, but the child should be given choices when possible.
CAUTION: Some of the images in the slide presentation associated with this chapter are of a graphic and disturbing
nature. These images are not meant to shock or upset, but rather to inform and instruct. Knowing in advance various
presentations of child abuse can better prepare the prehospital provider for exposure to actual instances of child abuse
and neglect.
Many people react emotionally to images of injured children; these responses are normal and vary from individual to
individual. Instructors are urged to use discretion in presenting these slides.

PHYSICAL ABUSE
Skin Injuries
Skin injuries are the most common and easily recognized sign of physical abuse. The
skin examination should be complete and thorough; it should always include looking for
cuts, scrapes, bruises (ecchymosis), burns, bites, redness, and swelling. See Images A
and B. If these injuries are not present, this should also be documented. For example,
“5-year-old girl with red, swollen right cheek. No tears, abrasions, or bruising seen.”
Diagramming the information on the ambulance call report is very important.
Skin injuries should be described in a consistent manner. If injuries are described
systematically and completely, an injury that might otherwise be missed is more likely to
be identified. For example, a child being treated for an apparent unintentional burn may
have other, less obvious injuries. The most readily visible injury may not be the only
one.
Bruises: Documenting the appearance and location of a bruise is important, as is how
the child and parent or caregiver states that it was incurred. The key to assessing bruising
is noting whether it is in an area where the child is unlikely to have sustained it
accidentally. Infants rarely bruise accidentally because they are not yet standing or
walking. Toddlers and other young, active children tend to incur bruises naturally on the
front of their bodies (eg, knees, shins, elbows, forearms, forehead) as they explore the
world and hit various objects. Bruises that take the recognizable shape of an object are
suspect. See Figure 1 and Image C for examples of accidental bruising.

Recognition

Child Abuse and Neglect

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13

Multiple bruises in various locations and that are different colors, generally indicating
different stages of healing, are suspect. In these cases, parents may say that the child
“bruises easily.” In general, the specific aging of bruises should be left to a clinician
specifically trained in child abuse.
Some common conditions can be confused with abuse. For example, mongolian spots,
which may appear to be bruises on the buttocks, are often found in dark-skinned children.
Burns: Scald burns are one of the more common inflicted burns in child abuse. The two
general patterns of scald burns are immersion and splash. Immersion burns are
characterized by clear lines of demarcation with no or few splash marks. The “donutpattern” burn on the buttocks or stocking pattern burns of the lower legs are typical. In
accidental burns, splash marks are common due to the child rapidly withdrawing from the
source of the heat. See Figures 2, 3, 4, and 5 and Images D, E, F, and G for examples of
immersion burns and splash burns.
Another type of burn seen in child abuse is an inflicted contact burn. This type of burn is
recognized by having a shape that duplicates the object used to produce it (eg, a cigarette,
a curling iron). In contrast, when a child accidentally touches a hot object and reflexively
withdraws, the shape of the burn tends to be irregular. Such unintentional burns are
commonly found on the hands or face. Intentional burns tend to be in less exposed areas
and are deeper and larger. See Figures 2 and 5 for examples of inflicted contact burns.
Adult Human Bites: Adult human bite marks strongly suggest abuse. Generally, in
human bite marks, no one tooth mark stands out, differing from an animal bite. Marks
from the canine teeth are more easily recognizable when the bite is inflicted by an adult
as opposed to by another child.
Bite marks on infants tend to be found on the genitals and buttocks, and are usually
inflicted as punishment. Older children tend to have bite marks that are associated with
assault or sexual abuse. In general, there are multiple, random bite marks that have a
well-defined appearance and may be associated with a sucking mark.
KEY POINT:

Skin injuries are the most common and easily recognized sign of physical
abuse. The skin should be examined completely and thoroughly, looking
for cuts, scrapes, bruises, burns, bites, redness, and swelling.

Fractures
Fractures are suspicious of abuse in the following situations:
• The skeletal injury is inconsistent with the history
• Unsuspected fractures are discovered in the course of the examination
• Fractures are multiple, symmetrical, or in different stages of healing
• Skeletal trauma is accompanied by other injuries (eg, burns) to other parts of the
body

Recognition

Child Abuse and Neglect

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14

Falls
Children who fall from a standing position or from a fairly low object less than the
child’s height (eg, a couch) rarely have serious injuries. Even falling down stairs usually
results only in bruises over different body sites, although sometimes a skull fracture may
be sustained. In general, it takes a fall from approximately greater than the child’s height
to sustain serious injury.
Injuries to the Face and Head
Unintentional injuries to the face or head usually involve the front of the body. Injuries
to the side of the face (temple area), cheeks, or ears are suspicious of abuse. A direct
blow to the mouth usually results in a ragged or linear tear of the lip(s), possibly
accompanied by a broken jaw or teeth.
Infants may sustain injuries during feeding by having a spoon or other object forced into
their mouth. A torn frenulum (the band of tissue connecting the tongue to the floor of the
mouth) may indicate forcing a nipple from a bottle or pacifier into the child’s mouth.
Considerable force is required to cause severe head trauma. High velocity impact injuries
or falls from extreme heights or onto extremely hard surfaces can result in serious injury,
and these events rarely occur without a consistent history.
Hair Loss
Hair loss, either inflicted by another person or self-inflicted, can be a manifestation of
child abuse. A child may pull out his or her own hair to relieve excessive stress.
Dragging a child by pulling on his or her hair can cause traumatic loss of hair. Trauma to
the hair and scalp can also be caused by use of excessive force during hair brushing and
certain types of hair braiding. In hair loss due to abuse, there is often blood beneath or at
the surface of the scalp.
Shaken Baby Syndrome
Shaken baby syndrome is most common in infants and children less than two years old.
A baby who is shaken violently can have severe head injuries. Shaking can damage
nerve tissue deep within the brain and tear the veins between the brain and the skull
lining, causing hemorrhages and cerebral swelling. The child may also have fractures of
the long bones. However, there may be no external evidence of trauma. Signs to look for
include decreased consciousness, seizures, vomiting, or other signs or symptoms of head
injury. Altered mental status may be the only sign that injury has occurred. The child
may have an unusual cry.
Although a definitive diagnosis must be made by a physician, recognizing the possibility
of shaken baby syndrome should trigger a suspicion of abuse.

Recognition

Child Abuse and Neglect

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15

SEXUAL ABUSE
Sexual contact or assault is frequently thought of as having occurred recently, ie, within
the past 72 hours. In these cases, most often a child will complain of pain, bleeding, or
discharge from the urethra, vagina, or rectum. More insidious, but also common, is the
chronic “hidden” abuse that has occurred in the preceding weeks or months. These
children may exhibit symptoms of recurring nonspecific abdominal pain, vaginal
inflammation, or dysuria (difficulty or pain during urination). Regardless, in most cases
of sexual abuse, the physical examination is normal, and the diagnosis is made primarily
based on the history. Unless there is severe genital pain or gross genital bleeding, a
genital examination of a child suspected to be a victim of sexual abuse should not be
performed by prehospital personnel.
When a child is suspected of being a victim of sexual abuse, the following points are key
to appropriately managing the case:






Believe what the child says
Use the child’s own words, and document his or her statements in quotes
Never examine an unwilling child
Do not remove a child’s clothing for transport or before examination by an
appropriate clinician, unless it is medically necessary
Refer the child to a physician, a Sexual Assault Nurse Examiner (SANE), or other
health professional who has been specially trained in performing these
examinations

KEY POINT:

In most cases of sexual abuse, the physical examination is normal, and the
diagnosis is made primarily based on the history. Unless there is severe
genital pain or gross genital bleeding, a genital examination of a child
suspected to be a victim of sexual abuse should not be performed by
prehospital personnel.

EMOTIONAL ABUSE
Emotional abuse is a component of all forms of child abuse. It is a concerted attack on a
child’s development of self and social competence, although parents or other caregivers
may not do so on a conscious level. Most cases are mild and do not progress to the point
that child protection services are needed. However, early recognition of emotional abuse
can prompt early intervention and treatment.

Recognition

Child Abuse and Neglect

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