Defining child maltreatment

Health professionals are required to report suspected child abuse or neglect to the state Child Protective Services agency, which will then determine whether the injury meets an abuse definition; failure to do so can result in criminal prosecution. Although there are mandated reporting laws in every state of the United States, a broadly accepted operational definition of maltreatment has yet to be developed. Each state has its own definitions of child abuse and neglect that are based on standards set by federal law. Federal legislation provides a foundation for states by identifying a set of acts or behaviors that define child abuse and neglect. The Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C. §5101), as amended by the CAPTA Reauthorization Act of 2010, retained the existing definition of child abuse and neglect as, at a minimum:

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm (139).

Many state statutes use words such as “risk of harm,” “substantial harm,” “substantial risk,” or “reasonable discipline” without further clarification of these terms (74).

Generally, child maltreatment refers to child abuse, neglect, or a combination of these. The following section includes commonly accepted definitions for general and special forms of child maltreatment.

Types of abuse. Physical child abuse is defined as physical behavior by an adult toward a child that results in injury to the child. Physical abuse is nonaccidental physical injury (ranging from minor bruises to severe fractures or death) as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise harming a child, that is inflicted by a parent, caregiver, or other person who has responsibility for the child (140). Physical abuse is the most visible form of child maltreatment. Signs of physical abuse may include bruises, welts, cuts, broken bones, skull fractures, burns, poisoning, internal injuries of soft tissue and organs, and injuries to the bone and tissue joints of a child under the age of 18 years (23).

Sexual abuse of a child occurs anytime that a child is engaged in a sexual situation with an older person. Sexual abuse is identified as any sexual activity by an adult with a child where consent is either not given or cannot be given. Sexual activity by an older child with a younger child can be considered sexual abuse if there is a significant difference in age (generally 5 years), development, or size, and the younger child is unable to give consent. Sexual abuse can include voyeurism, showing children sexually explicit materials, or actual sexual penetration with penis, fingers, or objects. Regardless of the child’s age, molestation is illegal.

Emotional abuse is defined as acts or omissions that cause or could cause conduct, cognitive, affective, or other mental disorders. The American Medical Association describes emotional abuse as “when a child is regularly threatened, yelled at, humiliated, ignored, blamed, or otherwise emotionally mistreated.” Emotional abuse is more than just verbal abuse, it is an attack on a child’s emotional and social development. Emotional abuse can include belittling, cruelty, inconsistency, harassment, isolation, and ignoring.

Types of neglect. Physical neglect includes abandonment, expulsion from the home, failure to seek remedial health care or delay in seeking care, inadequate supervision, disregard for hazards in the home, or inadequate food, clothing, hygiene, or shelter (148).

Emotional neglect includes inadequate nurturance or affection, which fosters maladaptive behavior, and other inattention to emotional and development needs. It also includes refusal to obtain or delay in seeking psychological care, exposure of the child to extreme domestic violence, and permitting a child’s maladaptive behaviors.

Educational neglect includes permitting chronic truancy, failure to enroll a child in school, or other inattention to educational needs.

Medical neglect includes refusal to provide or delay in seeking adequate health care despite the availability of sources and health care provider recommendations.

Historical note and nomenclature

As mental health workers’ attention became focused on children and families in the 20th century, awareness of child maltreatment as a widespread epidemic arose and increased. Social acceptance of divorce and the women’s rights movement allowed women to escape from abusive household situations and report them to professionals, thereby spreading knowledge of the frequency and types of domestic abuse. This social movement to identify and protect victims of maltreatment was galvanized by the work of physicians like Dr. Caffey, whose 1945 description of the association of subdural hematomas and long bone fractures led to the recognition of shaken baby syndrome (22), and Dr. Kempe and his colleagues, whose 1962 paper on “battered child syndrome” is widely recognized as a catalyst in the history of child maltreatment prevention (76).

Symptoms and effects of child maltreatment

The Adverse Childhood Events Studies (ACE) have demonstrated that child abuse, neglect, and other circumstances that disrupt the parent-child relationship are significantly associated with many leading causes of adult death, such as stroke, cancer, and heart disease, and with heavy health service utilization. These disparate consequences, including depression and suicide, hypertension and diabetes, cigarette smoking, alcohol and other substance abuse, and fractured bones, bear compelling testimony to the vulnerability of children to stressful experience (American Academy of Pediatrics and Stirling 2008).

In this section, we will discuss the common clinical symptoms, effects, and costs of child maltreatment, including physical abuse, child neglect, and special types of maltreatment.

Physical abuse. Seven-year-old Samuel, who had a history of partial complex seizures, was referred to the neurologist due to increased difficulty with memory and concentration. He was also reported to engage in aggression against peers and adults. On visual examination of the head, the neurologist noted multiple scars on the neck and face. A fresh mark on his neck resembled the loop of a belt. Samuel reported multiple trips to the emergency room following a broken arm and “hurt shoulder.” Samuel’s mother described him as “accident prone” and impossible to deal with. When the neurologist inquired about the belt mark, Samuel stated that he was always bad and got a lot of whippings from mom. Samuel’s story provides an example of the health effects of child physical abuse, which will be discussed at length in this section.

Children who have been abused or neglected early in life may later present with significant behavior problems, including emotional instability, depression, and a tendency to be aggressive or violent with others. These worrisome behaviors may persist long after the child has been removed from the abusive or emotional environment. Neurobiological research has shown that early abuse results in an altered physiological response to stressful stimuli, a response that deleteriously affects the child’s subsequent socialization (American Academy of Pediatrics and Stirling 2008).

The scientific literature identifies multiple sequelae that correlate with the occurrence of child physical abuse (78). Five potential domains of impaired functioning have been identified in physically abused children: (1) aggressive behavior, (2) poor social competence; (3) trauma-related emotional symptoms; (4) developmental deficits in relationship skills; and (5) cognitive or neuropsychological impairment. Several long-term effects of child physical abuse have also been identified. This section will discuss these 5 domains as well as long-term effects and costs of child maltreatment.

Aggressive behavior. Physically abused children tend to exhibit aggression (33). A published longitudinal study suggests that child neglect in the first 2 years of life may be a more-important precursor of childhood aggression than later neglect or physical abuse at any age (79). Teachers and parents of physically abused children rate them as more aggressive and oppositional than do teachers and parents of their nonabused peers (40; 47). The aggression is not only toward other children but also toward adults (67; 122).

Poor social competence. Children who experience rejection or neglect are more likely to develop antisocial traits as they grow up. Parental neglect is also associated with borderline personality disorders and violent behavior (115; 140; 141).

Research indicates that physically abused children are less socially competent than their nonabused peers. For example, physically abused preschoolers have been shown to initiate fewer positive interactions with peers and adults and avoid peers more often (64; 70). Parents also perceive physically abused children as less socially skilled and mature than their non-abused peers (67; 81). Abused children frequently have insecure attachments to their caregivers, which results in difficulties sustaining interpersonal relationships later in life.

Early maltreatment (physical or sexual abuse, neglect, or exposure to violence and fear) can deprive the child of the tools needed to adapt to a larger social environment. In addition to denying the developing child necessary social interactions, early maltreatment can alter the normal child’s neural physiology, significantly changing the expected responses to stress and affecting the child’s ability to learn from experience (American Academy of Pediatrics and Stirling 2008).

Social difficulties. Children who experience rejection or neglect are more likely to develop antisocial traits as they grow up. Parental neglect is also associated with borderline personality disorders and violent behavior (115; 140; 141).

Trauma-related emotional symptoms. When children experience traumatic events, the consequences are often characterized by internalizing problems such as anxiety or depression. As child physical abuse is a potentially traumatizing event, research has investigated the presence of posttraumatic stress disorder among children who have experienced child physical abuse. Findings indicate that the majority of children do not show posttraumatic stress disorder following child physical abuse; rates range from 0% to 50% (45; 108). Child physical abuse has been associated with mental health problems such as depression, overanxious disorder, generalized anxiety disorder, and agoraphobia (61; 71). When child physical abuse is combined with other risk factors, it contributes to longer term disorders such as dysthymia and conduct disorder (71).

Characteristics of the abuse and of the child may predict symptoms. For example, severity and duration of abuse predict individual differences in depression and anxiety. With regard to the child, abuse-specific attributions (ie, self-blame and guilt) have been associated with symptoms. Negative attributions about self are associated with internalizing symptoms such as depression. Negative attributions about others behavior toward the child (eg, “People say bad things behind my back”) have been associated with externalizing symptoms (18). Children with posttraumatic stress disorder who have experienced multiple types of maltreatment, particularly experiences of sexual abuse and witnessing of domestic violence, tend to suffer from comorbid mood disorders (major depression or dysthymia), oppositional-defiant disorder, or ADHD (mainly inattentive subtype).

Developmental deficits in relationship skills. Maltreatment of very young children is associated with insecure attachment and developmental problems that may last through the course of a lifetime. When children have an anxious attachment to key adults in their life, they are expected to develop poor relationship skills and demonstrate aggressive behavior in established relationships. Research has shown that nonsecure attachment in infancy relates to poorer social competence and increased aggression during the school years (82; 101). Further, research is showing that in late adolescence and early adulthood, insecure attachment relates to difficulty managing conflict and low confidence in regulating negative mood (38).

Cognitive impairment. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (44). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (143; 141). Data from another study suggest that exposure to early life trauma, which includes child abuse and neglect, can result in a cascade of neurobiological changes associated with cognitive deficits in adulthood that vary according to the type of trauma experienced (65). Compared to their nonabused age mates, physically abused children are more likely to show skill deficits in receptive language (92), expressive language, reading ability (20), initiation of tasks (04), comprehension and abstraction, auditory attention, and verbal fluency (134). Physically abused children perform lower on math and reading than nonabused peers and are 2.5 times more likely to repeat a grade in school (51). In addition, research on emotion processing has shown that maltreated children process emotional information differently than non-maltreated children. They tend to use different cognitive resources when attending to the cues that may be present for positive and negative affect (110).

A cohort study of 7223 children showed that both child abuse and neglect are independently associated with impaired cognition and academic functioning in adolescence. These findings suggest that both abuse and neglect have independent and important adverse effects on a child’s cognitive development (96).

Neurologic impairment: adverse brain development. Human neuronal pathways must be stimulated during critical periods of development for natural maturation, pruning, synaptogenesis, and myelination to occur. The process of neural plasticity continues into adulthood, with gender- and age-specific differences in brain development. Maltreatment in childhood occurs during sensitive periods of brain development, and different brain regions may have unique windows of vulnerability (90).

The study of neurobiological consequences of child maltreatment has included animal and human subjects. A laboratory model of human parental neglect is maternal separation of animals in early life. Animal studies have established that nurturing by a caregiver is a biological necessity for physical and psychological growth and that experience affects physiological variables, including brain structure and function. Studies of infant rats and monkeys show that animals deprived of maternal touching suffer deficits in social, behavioral, and cognitive development. In rats, even brief maternal separations or trauma exposure during infancy have been shown to affect the functioning of the limbic hypothalamic-pituitary-adrenal axis and glucocorticoid receptor gene expression in the hippocampus and frontal cortex. Differences in mothering of rat pups have been shown to affect their catecholamine regulation and fear response mechanisms.

Research on the effects of trauma on emotion processing and brain functioning suggests that the stress of maltreatment results in adverse brain development. A brief review of the major biological stress systems affected by child maltreatment is important for the following reasons: (1) these are the major systems implicated in adult mood, anxiety, and impulse control disorders; (2) pharmacological treatments may reduce the effects of child maltreatment by targeting these systems; (3) alcohol and various illicit substances target these systems by damping down hyperarousal or dysregulated stress systems; and (4) a hyperaroused or primed stress system may lead to behavioral manifestations of motor restlessness and deficits in learning and memory.

The stress response is a physiological coping response involving the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic and immune systems. The action of stress-sensitive hormones, such as glucocorticoids, is important in determining gene expression in the stress response system. Increasing evidence indicates that maltreated children can have high hypothalamic-pituitary-adrenal-axis, growth hormone, and catecholamine dysregulation at varying levels depending on the chronicity, severity, and types of maltreatment. Evidence indicates that early chronic stress could lead to an initial hyperactivation of the HPA axis, which could progress over time to hyporeactivity (91). The specific brain regions most vulnerable to early stress and adverse circumstances include the hippocampus, amygdala, prefrontal cortex, and corpus callosum, which are influenced primarily by the hypothalamic-pituitary-adrenal axis and catecholamines. The hippocampus is especially significant in responses to child maltreatment because it plays a dominant role in the pathophysiology of posttraumatic stress disorder, generalized anxiety, and panic disorder.

In human clinical studies, maltreated children have not only demonstrated neuroendocrine and neurotransmitter dysregulation, but also volumetric brain differences associated with psychiatric disturbances. Studies showed maltreated children with posttraumatic stress disorder excreted greater concentrations of baseline urinary norepinephrine and dopamine compared to overanxious non-maltreated children and healthy children (42). The maltreated children also proved to have greater concentrations of urinary-free cortisol than healthy children and greater concentrations of urinary epinephrine than overanxious non-maltreated children. In further research, children with posttraumatic stress disorder showed smaller intracranial and cerebral volumes than control participants (43).

A cross-sectional investigation of brain development in medically healthy youth with chronic posttraumatic stress disorder due to maltreatment and non-traumatized healthy control subjects demonstrated that maltreated children and adolescents with posttraumatic stress disorder had smaller structural measures of intracranial volumes, cerebral volumes, and midsagittal corpus callosum areas and larger lateral ventricles than did controls (32). Intracranial volumes correlated positively with the age of onset of abuse and negatively with abuse duration and posttraumatic stress disorder symptoms. The positive correlation of intracranial volumes with age of onset of posttraumatic stress disorder suggests that traumatic stress is associated with disproportionately negative consequences if it occurs during early childhood.

Thus far, research at the neuroendocrine level is the most advanced. However, the mechanism of how the HPA axis might link stress and psychopathology is unclear. Research on structural and, even more so, on functional differences is less advanced. Current literature findings of structural brain differences associated with maltreatment include the following: reduced corpus callosum in children and adults, normal hippocampal volume during childhood but reduced hippocampal volume in adults, and greater amygdala volume (90). Interpretations and conclusions on the effects of child maltreatment must be made with caution due to the limitations of existing research, which includes a paucity of studies of epigenetic effects of maltreatment (89). Further research is needed as a better understanding of the neurobiological consequences of child maltreatment is necessary if we are to optimize effective treatment interventions.

Long-term effects. Long-term effects include those that span a child’s development and those manifest in adulthood. Regarding the former, children who experience physical abuse during infancy show slower development than nonabused children from the same cohort. These deficits are manifested in low school readiness early on and reduced academics and social competence as the child moves through school. The most common effects of child abuse in adulthood include mental health problems, antisocial and aggressive behavior, and a significant risk of repeating the cycle of child abuse on one’s own children.

Adults who were physically abused as children face an increased risk of mental health problems and behavior problems. Negative health outcomes for adults have been found to be associated with a history of child maltreatment and other household dysfunction (57). Longitudinal and retrospective studies show that adults maltreated as children were more likely to show higher rates of criminal conviction, substance abuse problems, antisocial personality disorder, dating violence, marital violence, suicidal attempts, psychiatric and interpersonal problems (88; 86; 109; 50). An 18-year longitudinal study of 1265 children in New Zealand found victims of physical punishment and maltreatment to be at greater risk for juvenile offending, substance abuse, being a victim of violence, and suicide attempts (58). For some adults, being a victim of physical abuse as a child affects later parenting. Research on intergenerational transmission of physical abuse shows that one third of abuse victims go on to abuse their own children (72).

Social and financial costs of child maltreatment. The short-term and long-term effects of child maltreatment exact significant costs socially and financially. The financial costs associated with treatment of those social problems are vast but are the least of the expenses.

In a CDC study, Fang and colleagues found that the estimated average lifetime cost per victim of nonfatal child maltreatment is 0,012 in 2010 dollars, including ,648 in childhood health care costs; ,530 in adult medical costs; 4,360 in productivity losses; 28 in child welfare costs; 47 in criminal justice costs; and 99 in special education costs. The estimated average lifetime cost per death is ,272,900, including ,100 in medical costs and ,258,800 in productivity losses. The study found the total lifetime estimated financial costs associated with just one year of confirmed cases of child maltreatment (physical abuse, sexual abuse, psychological abuse, and neglect) is approximately 4 billion. In sensitivity analysis, the total burden is estimated to be as large as 5 billion (55).

Although it is known that child abuse and neglect represent major threats to child health and well-being, little is known about the consequences for adult economic outcomes. Currie and Widom used a prospective cohort design looking at court substantiated cases of childhood physical and sexual abuse and neglect during 1967-1971 (Currie and Widom 2010). These were matched with non-abused and non-neglected children and followed into adulthood (mean age 41). Outcome measures of economic status and productivity were assessed in 2003-2004 (N=807). Results indicate that adults with documented histories of childhood abuse and/or neglect have lower levels of education, employment, earnings, and fewer assets as adults, compared to matched control children. Maltreatment appears to affect men and women differently, with larger effects for women than men. These new findings demonstrate that children subjected to abuse and neglect experience large and enduring economic consequences.

Child neglect. Child neglect refers to parental omissions in care regarding healthcare, education, supervision, protection from all hazards in the environment, physical needs (eg, clothing, food), and emotional support resulting in actual or potential harm (49). Victims of child neglect may exhibit a variety of emotional or behavioral problems across multiple domains, especially in social and physical development. Physical development problems may include failure-to-thrive syndrome in infants, indicated by growth delay with postural signs (poor muscle tone, persistence of infantile postures) and behavioral signs (unresponsive, minimal smiling, few vocalizations). Delays in cognitive functioning may include deficits in language, academic delays, and lowered intelligence scores. Delays in social or behavioral development may be manifested through avoidance and resistance of the primary caregiver, passivity, reduced play interactions with parents, isolative play in preschoolers or school-aged children, and an increased risk for delinquency and criminal behavior in adolescents. Neglected children frequently attach “too eagerly” to health care professionals because they are so desperate for love and attention.

Medical neglect is sometimes not considered in medical settings until puzzling symptoms or persistent noncompliance by the caregiver lead to this consideration. The most common form of medical neglect involves a lack of adherence to appointments or recommendations, resulting in actual or potential harm (ie, a parent fails to give her child a proper dose of medication). When adherence to medical guidelines is a possible concern, it is useful to document and review precise directions in simple language. It is frequently useful to have the parent sign a “contract” with the health care provider. This indicates a mutual understanding of what needs to happen to promote optimal health. This policy will provide a paper trail that includes documentation to justify involvement of Child Protective Services if guidelines are not followed. If a patient presents with vague psychosomatic symptoms, physicians should be watchful for signs of factitious illness by proxy, which will be discussed at greater length in the next section.

Special cases of child maltreatment. This section will provide an overview of 2 special forms of child maltreatment: abusive head trauma (preciously known as shaken baby syndrome) and pediatric condition falsification (previously Munchausen syndrome by proxy).

Abusive head trauma. The most serious causes of morbidity and mortality from child abuse are injuries to the central nervous system. Abusive head trauma affects one in 4000 to 5000 infants every year (75). Shaking was the most commonly reported mechanism of injury described in a series of abusive head trauma cases in which perpetrators admitted abuse (68% of 81 cases) (30). Abusive head trauma was previously referred to as “shaken baby syndrome.” The term “shaken baby syndrome” is sometimes used inaccurately to describe infants with impact injury alone or with multiple mechanisms of head and brain injury and focuses on a specific mechanism of injury rather than the abusive event that was perpetrated against a helpless victim (30). Therefore, for medical purposes, the American Academy of Pediatrics recommends adoption of the term “abusive head trauma” as the diagnosis used in the medical chart to describe the constellation of cerebral, spinal, and cranial injuries that result from inflicted head injury to infants and children (30). The term “shaken baby syndrome,” however, can be applied to infants who undergo vigorous shaking that leads to acceleration-deceleration injuries to the brain. These infants generally present at less than 1 year of age with seizures, vomiting, lethargy or bradycardia, hypotension, respiratory irregularities, coma, or death. Initial medical efforts for any traumatic brain injury require immediate attention to life-threatening concerns, such as increased intracranial pressure, abnormal tone, evaluation for skull fractures, contusions, risks for ischemia, and axonal damage. Retinal and subarachnoid hemorrhages are strongly associated with abusive head trauma (75). Secondary brain injury resulting from hypoxia, ischemia, and metabolic cascades contributes to poor outcomes (30). Current guidelines for imaging suggest that CT is the first investigation of choice, a recommendation based on the widespread availability and technical ease of performing on admission (75).

The term “Munchausen syndrome by proxy” includes both factitious disorder by proxy and also pediatric condition falsification. The American Professional Society on the Abuse of Children recommended that the child who is the victim of this abuse be diagnosed with “pediatric condition falsification” and that the psychiatric diagnosis of factitious disorder by proxy be reserved for the caretaker who causes the abuse (120). Pediatric condition falsification is a form of child maltreatment in which an adult falsifies physical or psychological symptoms, causing the victim to be regarded as ill or impaired by others (120). A child who is subjected to this behavior is coded as “child abuse” in the DSM-IV-TR (120). Pediatric condition falsification is sometimes also referred to as medical child abuse. Whether it is called “Munchausen syndrome by proxy,” “pediatric condition falsification,” or simply “child abuse,” what remains as the central issue of importance is that a caregiver causes injury to a child that involves harmful or potentially harmful medical care (125).

A 9-month-old infant named Samuel was admitted almost monthly to the children's hospital with complaints of bloody diarrhea. This was never witnessed until the mother brought the diaper to clinic as “proof.” It contained a bloody red streak with a small amount of guaiac-negative stool in the middle of it. Investigation of the blood revealed that it was mother's type, and it was thought to be menstrual blood. The mother left the hospital against medical advice, stating that she needed a better medical opinion. It was discovered that the child was admitted to another hospital, and Child Protective Services became involved with the treatment of the child. A report was made to child protective services.

This case provides an example of pediatric condition falsification. It is a form of child abuse in which a parent (usually the mother) fabricates or produces illness in a child or creates physical signs that persistently result in unnecessary medical treatment (128). Like other forms of abuse, pediatric condition falsification is one extreme in a spectrum of behaviors, with less serious variations being exaggeration of symptoms, not believing a doctor’s reassurance that the child is healthy, or seeking excessive care for a child who is truly medically ill. Pediatric condition falsification involves a mixture of exaggeration, false reporting, and symptom induction. Negative medical consequences, including death, have been well documented (03). The horror of psychological morbidity can include withdrawal, hyperactivity, hysterical disorders, and personal adoption of factitious behavior in adolescence (94).

In the typical course of pediatric condition falsification, the caregiver (usually the mother) brings the child for medical treatment while denying knowledge of the cause of the symptoms. The caregiver may also fabricate symptoms or may actually cause signs of illness in the child. In pediatric condition falsification, abusers often appear as wonderful parents with close relationships with their children; this appearance may provide a false sense of reassurance. The caregiver is initially perceived as attentive and caring, making it difficult to decide whether a case is pediatric condition falsification or simply an overanxious parent. Pediatric condition falsification differs from parental anxiety in that the overanxious parent does not want the child to be ill and usually shows relief when reassured that the child is well, whereas in Munchausen by proxy syndrome, abusers tend to focus relentlessly on the “medical problem.”

Pediatric condition falsification can be identified by the perplexing absence of any apparent tangible benefit to the abuser. It is different from malingering in that there is no tangible secondary gain; the abuser is usually seeking attention and connection, not financial gain or child custody, and uses the child as an intermediary to develop a relationship with the medical community. Many of the abusers have no other mental illness, although some disturbance of attachment drives the abuse.

Commonly noted indicators of pediatric condition falsification include:

	• A child presents with 1 or more medical problems that do not respond to treatment or that follow a puzzling course. The physical or laboratory findings are highly unusual, discrepant with the history, or clinically impossible.
	• The signs and symptoms of a child’s illness fail to occur in the parent’s absence. (Hospitalization and careful monitoring may be necessary to establish this causal relationship.)
	• A parent (usually the mother) seems medically knowledgeable, enjoys the hospital environment, and often expresses interest in the details of other patients’ medical problems.
	• A highly attentive parent is reluctant to leave her child’s side and seems to require constant attention herself.
	• A parent appears unusually calm in the face of serious difficulties in her child’s medical course while being highly supportive and encouraging of the physician; alternatively, she is angry, devalues staff, and demands further interventions.
	• The suspected parent may have worked in the health care field or profess interest in the field.
	• The family history includes unusual or numerous medical ailments that have not been substantiated, such as a similar unexplained illness or death of a sibling.
	• A parent has an unusual or puzzling illness, often displaying symptoms similar to her child’s medical problem.
	• A parent has an emotionally distant relationship with her spouse. The spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized.
	• A parent reports dramatic negative events, such as house fires or car accidents, which affect the family while her child is undergoing treatment
	• A parent seems to have an insatiable need for adulation or makes self-serving efforts at public acknowledgment of her abilities.

Controversy continues to surround the exact criteria for this diagnosis, and the DSM-IV lists it as a criterion set in need of further study. Some health care professionals are not aware of it (105); for others, it does not readily come to mind when treating relevant patients. It is most commonly identified in young children, but often after several months or years of unexplained illnesses and unnecessary medical procedures. If foul play is suspected, the following are recommended:

	• Although illness-inducing behaviors may occur in the hospital, hospitalization may be the only way to thoroughly evaluate the ill child, observe parent-child interactions, and develop a plan of surveillance. Documentation of the time-course of the illness may be useful in identifying causal relationships.
	• Convene an interdisciplinary team of all involved professionals as soon as possible to compare impressions and form a plan. If the child has seen specialists from different medical centers, all should be involved. Involve social service and psychological staff as early as possible for consultation and evaluation of suspected pediatric condition falsification. It is not uncommon for professionals to disagree on whether they suspect abuse or not, but an investigation is necessary.
	• Keep careful documentation of all suspicions and steps taken by medical staff to verify a pediatric condition falsification diagnosis.
	• Obtain thorough, detailed medical histories from the patient and other family members. Details of the histories should be carefully verified with actual medical records from all physicians and hospitals. Autopsy reports of siblings may be helpful. Limit the child’s food to hospital food only. Observe the parent during the patient’s mealtimes to watch for interference with hospital food.
	• Medication should only be administered by hospital staff.
	• Check blood, urine, and stool. Carefully store laboratory samples until the best plan is developed for sophisticated analysis. Do thorough toxicology screens. Emetics or phenolphthalein are sometimes found in cases of unusual gastrointestinal symptoms. Video sleep EEGs sometimes provide a useful way of monitoring if symptoms are suggestive of seizure-like activity.
	• Obtain thorough social histories from other family members. Inaccuracies may bolster evidence of deception. Interviews with the suspected parent’s spouse, parents, and siblings are often particularly useful.
	• Encourage nursing staff to pay close attention to parent-child interactions. Documentation of feeding, diapering, and handling of equipment or invasive lines is often useful. Also, nursing staff should note unusual interactions between the parent and the staff; sometimes the parent treats hospital staff as her social circle.
	• Institute controls so the suspected parent does not have access to the child’s records. If the parent insists on access, ensure that the access is carefully supervised. Parents should not have the chance to tamper with any charting.
	• Make an effort to personally interview every reported witness to any illness episode. Differentiate between true eyewitness reports and secondhand reports. For example, it is crucial to determine whether a witness to a child’s apnea or seizure was present when the episode began.
	• If possible, obtain psychiatric and psychological evaluations of both the parent and the patient. Use evaluators with detailed knowledge of pediatric condition falsification.
	• Remember possible true medical comorbidity; it is possible to have an explained medical disorder coexisting with pediatric condition falsification.
	• The local child protection agency or the police should be brought into the case before the parent is confronted. It is often the responsibility of physicians and mental health professionals to help educate these other professionals on pediatric condition falsification.

Because cases are so highly varied, little information exists on the treatment of this disorder. Often, the child is removed from the custody of the caregiver while the caregiver undergoes therapy, then the 2 are reunited gradually as therapy proceeds. Clinical experience and chapter summaries were used for charts above. Further information on confronting the abuser and determining treatment plans is available in the book Hurting for Love: Munchausen by Proxy Syndrome (116), Chapter 7 in American Professional Society on Abuse of Children (106), and Chapter 18 in Treatment of Child Abuse (03).

Multiple abuse experiences. It is important for clinicians to bear in mind that victims of child abuse and neglect are frequently subjected to multiple types. Child neglect is the most common form of maltreatment, yet little is known about the additive consequences of other forms of abuse combined with it. Cases of multiple forms of abuse are often recorded merely as neglect cases; this prevents the children from receiving the appropriate investigation and treatment. Another danger of failing to distinguish pure types of maltreatment from mixed combinations is that the effects attributed to a particular type of maltreatment may be wrongly estimated or misattributed. Little research has yet focused on distinguishing the developmental effects of single versus multiple forms of maltreatment or “dose-related” responses to chronic versus acute maltreatment.

Etiology and risk factors for child maltreatment

Multiple diverse factors may combine to put a child at risk for being abused or neglected (142). For example, abuse or neglect risk may be high in one family due to parental substance abuse, child noncompliance, and low parenting skills; it may be high in another family due to domestic violence, parental depression, and child problems at school. Basically, maltreatment occurs when risk factors are greater than protective factors and stressors exceed the supports (60). Risk factors for child maltreatment are generally related to the child, parent, family, or community.

Child correlates. Child factors that correlate with abuse risk include age, development, and emotional/behavioral difficulties. Some of the child problems noted earlier may be due to physical abuse, but these factors may also increase the risk of violent physical punishment. Children who are younger or developmentally delayed are at higher risk of abuse and neglect than are older and nondelayed children (08; 06; 131). With regard to child behavior, noncompliant children are at higher risk for being abused (15). Children with chronic medical conditions and other special caretaking needs are at higher risk for neglect. In fact, children with disabilities are 3.4 times more likely to be maltreated than nondisabled peers (129). In addition, children born of unplanned or undesired pregnancies and those born of multiple gestation pregnancies are also at higher risk (10).

Schmitt identified 7 developmental phases when a child is at high risk for dangerous or even deadly abuse. These phases included colic, awakening at night, separation anxiety, normal exploratory behavior, normal negativism, normal poor appetite, and toilet training resistance. The 2 behaviors most commonly associated with fatal abuse are colic and toilet training (114). Crying is a common trigger for child abuse and is the most common trigger for abusive head trauma (60).

Parent factors. No single trait or profile pinpoints an individual as likely to physically abuse his or her child, but a number of parental factors correlate with physical abuse risk. These broadly defined characteristics include a history of childhood abuse, cognitive impairments, affect regulation problems, behavioral problems, and psychiatric disorders. Roughly one third of adults who were physically abused as children go on to abuse their own children (72). Not only does this experience transmit the teaching of physical force as a way to parent, but adults who were physically abused as children are also at risk of multiple mental health problems that may interfere with their capacity to parent in a more positive way.

Young maternal and paternal age are also risk factors for maltreatment, and young maternal age is strongly associated with infant homicide (60).

With regard to cognitive factors, parent attributional biases affect discipline of children. Abusive parents view their children in a more negative light (13) and may distort beliefs about the motives of their child’s behavior (ie, “He left that toy out just to ruin my day”) or the child’s responsibility for the parent’s welfare (11). Lack of knowledge about childrearing may lead parents to have unrealistic expectations for their child’s behavior. When these are not met, the parent experiences frustration that results in the use of force towards the child (12). It has also been found that physically abusive parents are more likely to support the use of harsh punishment (123).

Difficulty regulating emotions such as irritability, sadness, anxiety, explosiveness, hostility, anger, and use of threats has been associated with harsh parenting (26; 123). Abusive parents have been shown to perceive their lives as more stressful than nonabusive parents do (98) and tend to use heightened emotion-focused coping, becoming reactive to stress (24). Behavioral problems such as low impulse control may result in negative comments, threats, and physical force toward a child (25). Adults who physically abuse their children have been shown to exhibit deficits in positive parenting such as attention, positive affect and social behavior, physical affection, and problem solving (12; 73).

Psychiatric disorders, such as depression (84; 137), posttraumatic stress disorder (54), and substance abuse (59), correlate with risk of physical abuse. Depression, especially postpartum depression, affects a child’s growth and development and may place the child at risk for maltreatment. Depression is a significant problem for both fathers and mothers (60). These disorders may make parenting and general problem solving difficult and hamper an individual’s capacity to regulate emotions.

Factors similar to physical abuse are associated with neglect. Parental substance abuse, in particular is a factor that places parents at significant risk of neglecting their children. Over half of neglectful parents meet criteria for a lifetime substance abuse disorder (27). Substance abuse has been identified in up to 79% of child protection cases and is the deciding factor in the majority of cases in which children are taken into custody and placed out of the home (16).

Family factors. Multiple family risk factors are associated with physical child abuse. These include poverty, unemployment, low maternal education, and single parenting. Having a non-biologically related male living in a single-female-headed home is also a risk factor for child abuse and fatal maltreatment (60).

Three categories of family factors correlate with physical abuse risk. These include volatile home environment, limited psychosocial resources, and general family stressors. A growing body of research has documented the relationship between domestic violence and child physical abuse. Children exposed to domestic violence are not only at risk for being physically abused, but they are also affected emotionally, cognitively, and behaviorally (60). Partner hostility is common in volatile families (56), and family interactions may be characterized by verbal abuse (31).

The potential for physical abuse has been associated with low levels of family cohesion and expressiveness (100). Physically abusive parents are often described as isolated (99) as they have limited contact with friends and have been shown to be generally dissatisfied with social supports (39). When resources are available, they tend to not use those resources (35).

Heightened family stressors such as family disruption and moves are common among families where physical abuse occurs (53). Other life stressors such as limited financial resources and poverty are predictors of physical abuse risk (145).

Family poverty is one of the most powerful risk factors for neglect. Families living below the poverty line are 22 times more likely to have a report of maltreatment, predominantly neglect (117).

Community factors. Studies examining community factors that relate to child abuse and neglect risk are limited, but existing research has identified 3 primary factors: (1) economic disadvantage, (2) instability and isolation, and (3) neighborhood burden. Communities with economic disadvantage have higher rates of child maltreatment than more advantaged communities (37). In addition, disadvantaged communities are characterized by high resident turnover, instability, vacant structures, and low organization (Zuravin 1989; 21), which limits the psychosocial support available to families. Further, neighborhoods that have greater childcare needs have higher rates of abuse (36).

Epidemiology

Over half a million children are physically abused, and over 1 million are neglected annually in the United States. Investigation of prevalence has also been conducted through national abuse prevalence studies that detect abuse that is reported as well as abuse that is not reported. These studies give a broader perspective of prevalence rates. The Fourth National Incidence Study of Child Abuse and Neglect included children investigated by Child Protective Services for maltreatment and children treated by professionals in the community. Applying the stringent Harm Standard definition of physical abuse, results indicated that 323,000 children exhibited demonstrable physical harm out of 1,256,600 children who were maltreated during the NIS-4 study year (2005-2006). The more than 1.25 million maltreated children correspond to one child in every 58 in the United States. An estimated 553,300 children were abused and an estimated 771,700 were neglected (118).

Treatment

Management of child maltreatment involves 4 potential components: (1) identifying and reporting the maltreatment, (2) forensic assessment, (3) medical assessment and treatment if indicated, and (4) child clinical or mental health assessment and treatment if indicated.

Identifying and reporting child maltreatment. The task of identifying a suspected child maltreatment case presents several challenges for the physician. Some types of child maltreatment may be readily apparent, whereas others (such as pediatric condition falsification) are more disguised; some physicians might find it easier to ignore these difficult-to-confront cases, but doing so may place the child in danger of continued injury. In a primary-care or specialty clinic setting, children may present with injuries clearly resulting from physical abuse (such as abusive head trauma, scald burns, or spiral fractures) but may also display medical and behavioral symptoms with unclear etiology (which would indicate factitious disorder by proxy, failure to thrive, medical neglect, or psychosomatic illness).

The most reliable indication that a child has been abused is disclosure to the health care professional. Otherwise, the assessment of whether maltreatment has occurred is best left with Child Protective Services, child abuse pediatricians or physicians experienced in this area, or law enforcement. Although we know that certain behaviors such as attention-deficit hyperactivity disorder (ADHD), oppositional-defiant disorder, and developmental disabilities put youth at a higher risk for physical abuse and neglect, these behaviors alone do not provide a sufficient basis for suspicion. It is important for health professionals to keep in mind that not all maltreated children will experience psychosocial or psychiatric difficulties, and the presence of a behavior often seen in maltreated children in no way verifies that abuse or neglect has occurred.

If social, emotional, or psychiatric problems are identified in maltreated youth, the family should be encouraged to seek further psychological or psychiatric evaluation. Recognizing symptoms of stress and mood disturbance in children is difficult. Some reactions to individual or family violence may include sleep disorders, obsession with a traumatic event, fear that another bad event will occur, fidgeting and thumb-sucking, conduct disturbances, regression, excessive attachment behaviors, hyper-alertness, and avoidance of stimulus related to a traumatic event.

When a physician or other professional suspects that a child is experiencing any type of abuse or neglect, the first course of action is an immediate assessment of safety. If the medical opinion is that the child is unsafe, that child should not leave the physician’s office until a report is made and child protective services intervention is in place to assure safety. Any type of maltreatment is an act that mandates a report to Child Protective Services or law enforcement by physicians or other professionals. By law, a report is required if the professional suspects abuse; neither an investigation nor evidence uncovered by the professional is required for a report to a protective agency. Although all 50 states have statutes that mandate reporting of suspected child abuse and neglect, each state carries different reporting laws. In some states, child maltreatment by a parent or caregiver is reported to Child Protective Services, and abuse by other adults is reported to law enforcement. In other states, all suspected acts of maltreatment, regardless of the role of the alleged abuser, are reported to Child Protective Services. If the physician is unfamiliar with the reporting laws of his or her state, the place to start is to make a report to Child Protective Services.

The detection and diagnosis of child physical abuse depends on the clinician’s willingness and ability to recognize suspicious injuries, conduct a careful and complete physical exam, and consider whether the caretaker’s explanation of the injuries is consistent with the injuries and the child’s level of development. The physician must also ensure the child’s immediate medical and safety needs are met (74).

When the physician suspects that child maltreatment has occurred and makes a report to Child Protective Services, a crucial next step is to ensure that the child is referred for appropriate treatment. Identified concerns should be addressed in a follow-up consultation with a mental health professional.

The forensic assessment. Once a report is made to Child Protective Services, the forensic assessment begins. Not all cases are accepted for investigation. A Child Protective Services caseworker or Law Enforcement officer typically conducts this investigation. In some states, therapists specially trained in interviewing children are involved. The interviewer will talk with the parent and child individually and interview other key people. After the investigation is complete, a decision will be made regarding the appropriate level of involvement for Child Protective Services. If Child Protective Services determines that there is evidence of child maltreatment, they will immediately develop a safety plan with the family and work toward getting the child and family into appropriate community and home-based services. Whether the case is presented in court depends on many factors. These include the policy and procedures of the state, county, or parish in which the abuse occurred, the severity of the abuse, and, most importantly, the current risk. Some Child Protective Services agencies work to divert cases from the courts and instead to move the family through a treatment process. When families are not actively completing objectives on their individualized case plan, Child Protective Services may ask the courts for assistance through ordering the parent to complete the objectives. In cases where a child is at serious risk of harm, the Child Protective Services agency may take the child into protective custody and place him or her in an out-of-home placement. Out-of-home placements can include foster homes, relative placements, emergency shelters, and group homes. Child Protective Services monitors a family until they successfully complete the case plan goals and the risk of further abuse or neglect is reduced.

Medical assessment and treatment. Medical assessment of the child can serve many purposes. First, medical assessment investigates whether the child has sustained an injury and determines the course of treatment required for healing. Second, medical assessment may be a means for gathering forensic evidence of abuse. Third, a medical assessment can identify health concerns to be addressed that may not have been previously identified. For example, advances in medical knowledge may allow the physician to identify mimics of abuse caused by another medical condition. Fourth, early identification of child abuse may prevent further abusive trauma.

Child mental health assessment and treatment. If Child Protective Services determines that abuse has occurred, the child and family may be referred for assessment to identify the clinical problems and risk factors that may have led to the abuse and determine the course of treatment with the family (132). The clinical assessment will include, at minimum, a comprehensive interview, gathering historical data and current symptomatology of the parent and child. Some clinicians will also use standardized measures to determine whether identified problems such as depression are occurring at a clinical level. Standardized measures can be administered pre- and post-treatment or periodically to assess treatment progress. Some common measures for clinical assessment of children and parents are shown in Table 1. Clinicians who use these measures must be trained on administration, scoring, and interpretation of psychological assessment tools or be supervised by someone who has this training.

Table 1. Common Standardized Clinical Assessment Tools

Domain		Measure
Children
	Abuse history	• Brief Assessment of Traumatic Events (BATE) (85)
		• Abuse Dimensions Inventory (ADI) (29)
		• Record of Maltreatment Experiences (ROME) (93)
	Depression	• Children’s Depression Inventory (CDI) (80) • Beck Depression Inventory (BDI) for adolescents
	Behavior problems	• Child Behavior Checklist (CBCL) (01)
		• Youth Self Report (YSR) (01)
		• Global Assessment Scale for Children (Kiddie-GAS) (119)
	Trauma-related emotional symptoms	• Trauma Symptom Checklist for Children (TSC-C) (17) • Child PTSD Symptom Scale (CPSS) (95) • Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI) (95)
	Anxiety	• Revised Children’s Manifest Anxiety Scale (RCMAS) (112)
		• State/Trait Anxiety Scale for Children (STAIC) (124) • Multidimensional Anxiety Scale for Children (MASC) (95) • Screen for Child Anxiety Related Disorders (SCARED)
Parents
	Abuse and trauma history	• Child Abuse and Neglect Interview Schedule-Revised (CANIS-R) (07)
	Violent behavior and abuse risk	• Child Abuse Potential Inventory (CAPI) (97) • Parent-Child Conflict Tactics Scale (CTSPC) (126)
	Clinical symptoms and adjustment	• Brief Symptom Inventory (BSI) (46)
	Depression	• Beck Depression Inventory (BDI) (14)
	Parenting skills and practices	• Alabama Parenting Scale (APQ) (121) • Parenting Scale (PS) (09)

An interdisciplinary assessment is required for a comprehensive diagnostic evaluation, including a physical examination and psychologic forensic interview of the child and perpetrator. A detailed history should be obtained, with particular emphasis on specific chronological events, differential diagnoses, and associated features. Information should also be obtained from parents, medical records, and Child Protective Services regarding history of domestic violence, substance use, and psychiatric disorders.

The assessment, which determines who needs treatment and which symptoms or problems are the focus of treatment, enables the clinician to develop a treatment plan. This plan is developed with the family and includes specific, concrete, realistic, and measurable goals that, when accomplished, signal the end of treatment. Techniques used in treatment should be “evidence-based,” meaning they should address these specific goals and be supported by research.

As noted in the section on etiology, the occurrence or recurrence of abuse and neglect is determined by multiple factors related to the child, parent, family, or community. The implications of a multidetermined etiology are that treatment must address factors that increase abuse risk in each of the systems listed above. Therefore, treatment must include the child, parent, and family and must consider the role of the community in risk of abuse or protection from abuse. Below, we briefly summarize some of the current therapeutic and pharmacological approaches to treatment.

Treatment of the child. Treatment of the child will vary depending on his or her specific experiences. In children exposed to trauma, the most common co-occurring conditions include disruptive behavior disorders, anxiety disorders, peer relation problems, and substance use disorders (34). Studies have also found that PTSD in children is a significant mediator between sexual trauma and disordered eating (69). Currently, well-validated treatments are available for the treatment of both internalizing and externalizing symptoms. In general, these treatments involve skills training and fall within the behavioral and cognitive behavioral framework. For example, evidence-based techniques for treatment of post-traumatic stress disorder include relaxation training, graduated exposure therapy, and cognitive restructuring (78).

Treatment of the parents. Treatment of parents may take a variety of directions depending on the identified problem, as well as a significant risk factor for reentry into the child protective services system (135). Evidence-based techniques are published for addressing some of the common problems seen in parents who physically abuse children. Behavioral parent training has proven effective for increasing parenting skills (107; 147; 102). Cognitive behavioral treatment techniques are effective for improving management of anger (103; 104), reducing anxiety and posttraumatic stress disorder (111; 62; 63), managing depression (68; 83), and reducing cocaine use (19). Behavioral parent training involves teaching basic parenting techniques, such as setting up rules, limits, consequences, rewards, and basic discipline in the home.

Parental substance abuse is a major risk factor for child maltreatment, especially in neglect cases. It is also a significant risk factor for reentry into the child protective services system (135). To assure safety for the child and increase the parent’s capacity to parent, specific substance abuse treatment should be utilized.

Family therapy. Family therapy is an important modality for addressing family communication and problem solving skills (02; 113). Families need professional and personal support to help them resolve guilt and frustration and to stop negative interactions that result in conflict. In some cases, partner violence must be addressed to produce a safe environment for the child. In a study, physically abusive parents and their children who were assigned to family therapy and cognitive behavioral treatment showed greater improvements in child-to-parent violence and child externalizing behavior (eg, aggression), parental distress, abuse risk, and family conflict and cohesion than did families who received routine community service (77; 78)

Parent and child dyadic therapy. A treatment called parent-child interaction therapy has been adapted for physically abused young and school-aged children and their parents (138; 66). Concealed in a separate room, the therapist observes the parent-child interaction while they are engaged in specific tasks and directly coaches the parent via an electronic device worn in the ear. Through this method, parents are taught how to maintain consistent limits, identify and implement effective time-out strategies, and manage their own emotions during negative interactions in order to decrease symptoms of disruptive behavior (136). This model has been scientifically evaluated in controlled trials with physically abused children and their parents. Results indicated that parents receiving parent-child interaction therapy had fewer reports of reabuse than parents receiving a parent education via a group format (28). Thomas and Zimmer-Gembeck showed increased parental sensitivity (136).

Comprehensive treatment models include treatment of the child, parent, and family rather than focusing on one system (ie, parent) only. In the research literature, 2 comprehensive models have shown promise with maltreating parents and their families: SafeCare and multisystemic therapy. SafeCare is an evidence-based parenting program that addresses social and familial risk factors for abuse and provides care both in the community and via in-home services (52). SafeCare, and its precursor Project 12-Ways, has documented gains in several targeted areas such as child management, job training, home safety, and social support (Lutzker et al 1998; 52). Program evaluations demonstrate reduced abuse recidivism in comparison with families who did not receive this intervention program (87), although short-term improvements have not been maintained over time (144). Multisystemic therapy involves using a home-based model of service delivery, integrating evidence-based interventions, and viewing the family as key to effective behavior change (133). Short-term data on multisystemic therapy show significant effects in reducing parents’ psychiatric symptoms and stress, increasing parental control of child behavior, decreasing family problems, reducing children’s symptoms of depression and posttraumatic stress disorder (133), and increasing parental nonphysical discipline (130), although mixed results have been shown in smaller studies regarding maltreatment outcomes (133).

Pharmacotherapy. Pharmacotherapy to reduce or eliminate posttraumatic stress disorder, mood, or anxiety symptoms plays an important role in the treatment of child abuse. Common treatments include:

Selective serotonin reuptake inhibitors (SSRIs). These inhibit serotonin transport and are effective anxiolytic and antidepressant agents. No SSRI is FDA-approved for the treatment of PTSD in children, but fluoxetine and escitalopram are FDA-approved for the treatment of depression in children and adolescents (95). The SSRI fluoxetine has been evaluated in several studies, including randomized controlled trials. The TADS (Treatment for Adolescents with Depression Study) study has shown that cognitive behavior therapy and use of fluoxetine was more effective than either monotherapy in helping teenagers overcome depression (TADS team 2007). Possible side effects include induction of mania, GI symptoms including nausea and diarrhea (which are usually self-limited and resolve within a couple weeks), headaches, agitation, and suicidal ideation (as indicated by black box warnings on all SSRIs when used in children and young adults).

Mood stabilizers. These include both atypical antipsychotics, traditional mood stabilizers such as lithium, and anticonvulsants such as valproic acid. Minimal information and studies are available concerning the use of mood stabilizers. The disadvantage of some of these medications is the need for routine serum level monitoring, as well as thyroid and renal function with lithium and complete blood cell and platelet counts and liver function tests with carbamazepine and valproic acid. All mood stabilizers require comprehensive medical evaluation and follow-up, including periodic monitoring of fasting glucose and lipids with atypical antipsychotics. Lithium can also be fatal if taken in an overdose.

Stimulants. Stimulant medication may be useful in persons with a trauma history comorbid with ADHD. Stimulants can be helpful for the treatment of short attention span, hyperactivity, and impulsivity in some individuals; however, close follow-up is needed, as stimulants may potentially worsen the behavior of some anxious individuals who suffer from posttraumatic stress disorder (95).

Alpha adrenergic receptor agonists. The hyperarousal behaviors (hypervigilance and hyperactivity) evident in many individuals with posttraumatic stress disorder have been successfully treated with clonidine, an alpha2 adrenergic receptor agonist. Tolerance may develop to the therapeutic, but not sedative, effects of clonidine. Guanfacine, another alpha2 agonist, has fewer sedative side effects, but this medication has not been studied in a population of maltreated children.

Beta adrenergic blockers. Propranolol can be useful in the management of agitation and anxiety. The half-life of propranolol is short (about 4 hours); therefore, frequent administration is necessary when the child is small enough to make administration of long-acting formulations untenable. Side effects include hypotension and bradycardia. It can also cause increased airway resistance and blunting of the symptoms of hypoglycemia; thus, it is contraindicated in patients with asthma and patients with juvenile diabetes.

Professional challenges of assessment and treatment. As previously noted, child maltreatment involves multiple factors that cannot be addressed by one professional alone. The process of assessment and treatment requires close collaboration between professionals in the medical, mental health, child protective, and law enforcement fields to ensure that all aspects of child and family care receive thorough attention.

Collaborative professional efforts can help reduce the adversarial results that may come with reporting (ie, parents become angry at physicians who report them for suspected child abuse without notifying them) and help to ensure that a family follows through with treatment.

Frequently, families referred for mental health services may fail to actually engage in treatment. Barriers to families’ participation in treatment include lack of available resources, lack of transportation, no telephone, treatment being unavailable during parents’ hours away from work, being placed on a waiting list for treatment, fear of being mentally ill, the stigma of mental health treatment, and low esteem for mental health treatment. Medical and mental health staff can assist families with overcoming many of these barriers and maintaining treatment compliance in a variety of ways. First, even when conflict arises, the parents should always be encouraged to view themselves as a part of the team that is working to keep the child safe. Additionally, it is important that referrals be made in a nonjudgmental way (“I need help in providing comprehensive care for your child”).

When collaborative care providers work for separate agencies, they may have difficulties sharing verbal and written information. During the initial contacts with the family, the Health Insurance Portability and Accountability Act and written agreements regarding exchanges of information should be reviewed with the parent or legal guardian. If the 2 providers are from the same agency, families should be informed of the in-house confidentiality policy. In situations where providers represent different agencies, letters of agreement between the agencies may be necessary to clarify issues of confidentiality. Documents of this nature should be clearly discussed with clients. In all cases, clients should be informed about any potential limits or exceptions to confidentiality.

To ensure effective treatment, records must be kept up-to-date at all times, and detailed medical histories from the patient and other family members should be verified with actual medical records. It is important to remember that it is possible for an explained medical or developmental disorder to coexist with symptoms associated with child maltreatment. Additionally, record accuracy is essential because a paper trail documenting phone calls, missed appointments, and suspicious observations may determine whether Child Protective Services investigates a reported case.

Conclusion

Knowledge of the symptoms, risk factors, and treatment options for child maltreatment is essential if physicians are to effectively recognize and reduce the threat of harm to children. It is well known that histories of child maltreatment are associated with poor parenting skills, substance abuse, problematic parent-child interactions, domestic violence, and the intergenerational transmission of further child abuse. These poor outcomes appear to be mediated through maltreatment’s negative effects on biological stress systems and brain development. To provide safety for their young patients and guide the family toward a peaceful, healthy solution, physicians must be well equipped to (1) determine if they suspect maltreatment by understanding the definitions of abuse and neglect; (2) understand potential sequelae associated with child maltreatment and be able to identify such in the patients; (3) conduct an assessment to determine whether the case has met a threshold of suspicion for making a report to Child Protective Services; (4) understand basic treatment strategies to make an appropriate referral; and (5) immediately engage in the process of communicating and working collaboratively with other professionals. Cases will need to be carefully monitored to ensure that families are fully engaged in treatment and benefiting from the services being provided. All disciplines should strive to maintain positive relationships with key personnel from law enforcement, the courts, and Child Protective Services.

Given the enormous toll of child maltreatment on children, families, and society, it is clear that responding to child abuse is not enough. We must also direct our energies and research toward abuse prevention. Physicians and others working with children and families can educate parents regarding the range of normal behaviors in infants and children, provide anticipatory guidance, and be a resource when behavior becomes unmanageable for parents (74). Flaherty, Stirling, and The Committee on Child Abuse and Neglect have identified a number of things that pediatricians and others can do to help prevent abuse. These include talking to parents about their infants crying, being aware that children with disabilities are at increased risk, being alert to the signs and symptoms of intimate partner violence and postpartum depression, advocating for community programs and resources, and advocating for positive behavioral interventions and supports in schools (60).

Health care professionals are encouraged to provide community support to young victims. Careful identification, reporting, referral, and collaboration are all needed to interrupt a potentially continuous cycle of violence and protect children, our most vulnerable patients.