Child abuse

Physical, emotional and sexual abuse are all forms of violence. The abuse may be inflicted by a stranger, someone known and trusted by the child or the child's family, or someone within the family itself.

Estimates on the prevalence of child abuse vary widely. Various factors may complicate the estimates, including underreporting due to shame, secrecy or fear, as well as the failure to interpret an incident as abuse.


Physical abuse
Physical abuse can include battering, beating or otherwise physically harming or injuring a child. Denying a child needed medical treatment may constitute physical abuse in the form of medical neglect. Overzealously seeking unnecessary medical treatment -- as is the case with Munchausen's syndrome by proxy -- may also be considered physical abuse.

Emotional abuse
Emotional abuse may be an act of omission or a deliberate act of harm. Emotional abuse can be inflicted by parents, relatives, caretakers or strangers. Also referred to as mental cruelty or emotional mistreatment, emotional abuse is the most difficult type of abuse to define, identify and prove.
Emotional abuse includes specific behaviors as well as the lack of certain behaviors. For example:

Emotional abuse often involves verbal and emotional assault.
It exists when anyone belittles, criticizes, dominates, ignores, isolates or rejects a child on a continual basis or in an inappropriate manner.
Constant yelling and any other type of behavior that sabotages a nurturing environment is also considered emotional abuse.
Threatening a child with severe, unreasonable punishment or responding to a child's misbehavior in cold disapproval or withdrawal are other emotionally abusive behaviors.
Anyone who has experienced physical abuse, sexual abuse or neglect has also experienced emotional abuse.


Neglect
Neglect may take various forms.
Emotional neglect is passive or passive-aggressive inattention to a child's emotional needs. It's the failure to provide appropriate support, attention and affection. When a parent or caregiver has poor coping strategies, emotional neglect may be a response to a real or perceived problem in the child's behavior. In some cases, a child is ignored because the parent or caregiver is depressed, mentally ill or otherwise unavailable to the child. Substance abuse may be a contributing factor. Other times, a child may be ignored because he or she is unwanted or an unpleasant reminder of troubled times or former relationships. Emotional neglect also may include witnessing spousal abuse and receiving parental permission to use alcohol or drugs.

Physical neglect occurs when a parent or caregiver fails to provide basic needs, such as adequate food, sleep, shelter, safety, supervision or medical care. It includes abandoning the child, kicking the child out of the home or leaving the child home alone without adequate care or supervision.

Medical or dental neglect is the failure of a parent or caregiver to provide a child with necessary medical or dental treatment. Medical neglect may also constitute physical abuse.


Sexual abuse
Sexual abuse can include various behaviors that exploit a child's trust, including:
solicitation
exposure
voyeurism
kissing
fondling of breasts, genitals or other private body parts
sexual penetration
criminal sexual misconduct
involvement in or exposure to child pornography

Risk factors
Sadly, child abuse occurs across all socioeconomic levels and ethnic groups. Various family characteristics are associated with a higher risk of child abuse. For example:
Parents who are socially isolated or fear intimacy may have little outside support, increasing the risk of becoming abusive.

In cases of role reversal, the child may act as the caregiver for the parent or the parent may look to the child to meet emotional or sexual needs.

There may be confused role boundaries between parent and child, such as a parent using a child as a surrogate spouse.

A family may become organized around roles in which everyone is, at any given time, either being abused or acting as the abuser. For example, abused children may become abusive with siblings or peers. Abusive parents may "train" older siblings to be surrogate abusers of their younger siblings.

Within the family, factors such as marital conflict, domestic violence, financial stress, social isolation, and alcoholism or other forms of substance abuse may contribute to negative patterns of family functioning.
For parents or caregivers, contributing factors may include:

low self-esteem
poor impulse control
depression
anxiety
antisocial behaviors
unrealistic expectations for the child
a history of mistreatment as a child
Environmental factors also may be at play. For example, when poverty is coupled with depression, social isolation, lack of social support or violent crime in the community, the likelihood of child mistreatment increases.

For children, being young or having a disability may increase the likelihood of mistreatment. Traits such as aggressiveness, attention deficits, temper or behavior problems also may increase the risk.

Sometimes an adult's demeanor or behavior can indicate that a child may be at risk for abuse, such as an adult who:

shows little concern for the child, rarely responding to the school's requests for information, conferences or home visits

denies the existence of problems at home or school -- or blames the child for the problems

refuses offers of help to resolve problems at school

appears to be indifferent and unconcerned about the child or overtly rejects the child

considers the child bad, worthless or burdensome or describes the child with negative terms

constantly blames, belittles or berates the child

uses harsh physical discipline or asks teachers to do so

demands perfection or a level of physical or academic performance the child can't achieve

is unduly protective of the child or severely limits the child's contact with other children -- especially those of the opposite sex

looks primarily to the child to meet his or her emotional needs

offers conflicting or unconvincing explanations for a child's injuries -- or no explanation at all

seems apathetic or depressed

is abusing alcohol or other drugs

Cultural considerations
It's important to consider the involvement of cultural practice and belief in cases of suspected abuse. Common practices in various cultures may be considered abusive in Western society. One example is "coining," in which a coin or hard object is forcedly rubbed on the body to treat illness.

Protective factors and resilience
Supportive, emotionally satisfying relationships with family or friends and a connection to the community can help minimize the risk of child abuse. For children, personal characteristics such as optimism, high self-esteem, intelligence and hopefulness are protective factors that can buffer the effects of child abuse.

Symptoms
A child who's being physically, emotionally or sexually abused may develop a range of symptoms.
You may notice changes in the child's appetite or sleeping pattern. Depending on the type of abuse, he or she may have frequent genital infections and painful or more frequent urination or defecation. There may be unexplained bruises, welts, burns, fractures, lacerations or abrasions. Blood may appear in the child's underwear, and there may be bruising, swelling, discharge, sores or tearing around the genitalia or rectum. Physical symptoms of anxiety such as sweating and heart palpitations are also common. The child may fail to thrive or develop normally.

Psychologically, the child may feel inappropriate guilt or shame. The child may think he or she made a mistake or was a mistake, for example. Low self-esteem is common, as well as an increased startle response, a lack of concentration and nervousness around adults. The child may withdraw or become preoccupied with intrusive thoughts, flashbacks or images. He or she may be afraid of physical injury or death.

Socially, there may be a sudden change in personality or behavior. The child may demonstrate inappropriate or unusual sexual behavior or knowledge for his or her age. There may be poor or limited social activity or a decline in school performance. Young children may become clingy or whiny, possibly showing a sudden fear of well-known people, such as child care providers, relatives, teachers, coaches or family friends. Aggression toward adults or other children is possible.

Older children may run away from home or simply avoid going home or to certain locations. Delinquent behaviors, self-injurious behavior (such as burning, cutting or deep scratching) and poor hygiene are common. Other children may bathe excessively, avoid age-appropriate sexuality or become promiscuous.

Regression is a frequent response to sexual abuse, especially in preschool children. The child may suddenly revert to less mature behaviors, such as whining or thumb sucking. He or she may lose ground with previously mastered tasks, such as toilet training, separating or sleeping alone through the night.


Long-term consequences
Abused or neglected children are often unaware of healthier ways of life. As they get older, children with a history of abuse have a higher risk of developing conditions such as:
post-traumatic stress disorder
depression
anxiety
eating disorders
substance use disorders
personality disorders
phobias
Other long-term effects of child abuse may include difficulty establishing or maintaining relationships and challenges with intimacy and trust. An unhealthy view of parenthood and love may also emerge.


Coping
If a child tells you he or she is being abused, use the following strategies to help the child find comfort.
Remain calm. Remember that your tone of voice, body language and attitude will have a tremendous impact on whether the child feels comfortable talking with you. Talk to the child in private even if the child says it's OK to have another person present. Avoid reacting too strongly in front of the child or getting overly emotional. Instead, keep the focus on the child and his or her needs. Don't ask assuming questions or suggest what might have happened. Use open-ended questions such as, "What happened then?" You may need to seek support for yourself as well.

Make sure the child feels heard and believed. Use a statement such as, "I believe you, and I'm glad you told me." Acknowledge the courage it took to disclose the abuse. To any professionals involved in the situation, make public statements demonstrating your belief in the child's story. Let the child tell you about the abuse instead of making assumptions. Let the child know you're available to talk or even just listen at any time. Be sure he or she knows how to reach you. When you talk, focus on the child and his or her needs. Refrain from pressuring the child to say more than he or she is ready to.

Assure the child that he or she is not to blame. Let the child know that he or she is not at fault for what happened -- the responsibility for what happened belongs only to the abuser. Repeat statements such as, "It's not your fault."

Reassure the child that it's OK to talk about the experience, even if someone has threatened him or her to keep silent. Assure the child that he or she won't be punished for telling you about the experience. Use statements such as, "You did the right thing by telling me" and "I'm glad you told me." Abused children often find it helpful to talk about the abuse with a supportive adult who can validate their feelings and reassure them that it's OK to talk and they're not to blame.

Offer comfort. Use statements such as, "I'm so sorry that happened to you," "I'm so sorry you were hurt," and "I'll be here for you and will help you get through this." Provide extra support, protection and understanding, especially if the child has nightmares, night terrors or flashbacks. Express positive beliefs about the child's recovery and who he or she is as a whole person. Remind the child of his or her strengths and survivor status.

Take charge of the situation. Let the child know what you plan to do next and keep him or her informed at an age-appropriate level. Use statements such as, "I'm glad you told me. Now I can do something to help," "I will do everything I can to help you," and "What do you need?"

Report the abuse to the appropriate authorities. For specific reporting procedures, contact your local child protective services (CPS) agency. In most states, health care professionals are required to report child abuse or neglect to the state CPS agency or its equivalent. The agency will investigate reports of abuse and neglect and, if necessary, intervene to secure the safety of the child. Let the child know that you've told someone else what happened. Don't let the child be alone with the abuser, or eliminate the abuser's access to the child as much as possible. Also help the child seek appropriate medical attention.

Help the child feel safe. Children in abusive or potentially abusive environments need effective safety plans. To start, help the child identify one or two people he or she can call or go to for help, such as a trusted neighbor, friend, relative, teacher or coach. Also help the child understand potential warning signs of abuse, such as an adult raising his or her voice, coming closer to the child or repeating a command. Encourage the child to trust his or her own instincts on how to stay safe. For example, if the child is old enough, taking a walk or going to his or her room may help to avoid potential abuse. The child also needs to know how to call 911 if there's no other way to stay safe.

Assure the child that it's OK to have conflicting feelings about the experience. Encourage open discussion about the experience, acknowledge the child's feelings and offer various outlets for those feelings, such as play, artwork or other activities. Be ready and available to listen. Help the child understand that it's normal to feel confused about the abuser, especially if he or she is or was someone very close.

Offer affection. Use a statement such as, "I'll always love you." Continue to display normal affection, but allow the child to control the timing, frequency and type of touch.

Help the child seek additional support as appropriate. Counseling or other psychiatric treatment can help prevent or treat mental disorders related to abuse. Cognitive problem-solving therapy may help a child who has behavioral problems. Community-based home visitation programs have been shown to help prevent child physical abuse and neglect. Effective treatment often involves a collaboration of a multidisciplinary team including a social worker, psychiatrist, pediatrician and primary care doctor.

Age-appropriate support groups may be helpful for abuse survivors. Resources such as parent education programs, abuse prevention programs, anger management classes or groups, and Parents Anonymous support groups may be helpful for people who have identified themselves as abusers or at-risk adults.

Being involved in a child abuse situation can be extremely troubling. You may grieve the child's loss of innocence, trust and comfort. Keep in mind, however, that your concern can also instill hope and a positive opportunity for healing.