child abuse, the physical, sexual, or emotional maltreatment of a child. Child abuse predominantly affects children less than 3 years of age and is the result of multiple and complex factors involving both the parents and the child, compounded by various stressful environmental circumstances, such as inadequate physical and emotional support within the family and any major life change or crisis, especially those crises arising from marital strife. Parents at high risk for abuse are characterized as having unsatisfied needs, difficulty in forming adequate interpersonal relationships, unrealistic expectations of the child, and a lack of nurturing experience, often involving neglect or abuse in their own childhoods. Predisposing factors among children include the temperament, personality, and activity level of the child; order of birth in the family; sensitivity to parental needs; and requirement for special physical or emotional care resulting from illness, premature birth, or congenital or genetic abnormalities. Identification of abused children or potential child abusers is a major concern for all health care workers. Obvious physical marks on a child’s body, such as burns, welts, or bruises, and signs of emotional distress, including symptoms of failure to thrive, are common indications of some degree of neglect or abuse. Often, radiograph films to detect healed or new fractures of the extremities or diagnostic tests to identify sexual molestation are necessary. If abuse is suspected, the health care worker is required to make the necessary report. Special counseling services or support groups, such as Parents Anonymous, help families in which a child is abused. The nurse can play a significant role in preventing abuse by promoting a positive parent-child relationship, especially in the neonatal period, by teaching parents proper child care and disciplinary techniques, by explaining normal child development and behavior so that parents can formulate realistic guidelines for discipline, and by identifying parents at risk for child abuse. Compare child neglect. ▪ OBSERVATIONS: Abuse may reveal itself through physical, sexual, and/or emotional manifestations. Physical signs include unexplained bruising on soft tissue areas, such as the face, back, neck, buttocks, upper arms, thighs, ankles, and back of legs; multiple bruises at different stages of healing; burns; bites; cuts; unexplained head or abdominal injuries; multiple fractures; or x-ray evidence of multiple old fractures. The child may exhibit a fear of being hit or hurt. The child may be wearing long-sleeve shirts or similar clothing to hide injuries. Patterns of sexual abuse are evidenced as torn, stained, or bloody underclothing; bruising, redness, swelling, or bleeding of the genitalia, vagina, or rectum; statements that it hurts to walk or sit; and complaints of pain or itching in the genital area. The child may play out abuse with dolls or playmates. Emotional abuse may be exhibited in the child as inappropriate behavior or developmental delays in speech or social interactions. This may be accompanied by facial tics, rocking motions, and odd reactions to persons in authority. Emotional abuse is often seen in combination with other forms of abuse or neglect. Patterns of neglect are evidenced through a lack of care and attention. The child may have to provide care for himself or herself that is inappropriate for his or her age or developmental level. The child may be unresponsive or withdrawn, or may not respond to the caregiver’s coaxing. Nonorganic failure to thrive or malnutrition should be considered when a healthy baby appears to have lost weight or physical tone, especially when the infant is 25% below the expected growth curve. Diagnosis is typically made by social service, health care, and legal experts after history, investigation, and physical examination. A physical exam is conducted to show injuries or evidence of past injuries and general state of health and hygiene (height or weight parameters that are less than expected, malnourishment, and unkempt appearance). Information, drawing, or play behaviors from child that include evidence of abuse are also diagnostic tools, as are observation of child-parent interactions (eye contact, touching, verbal interaction, and/or parental concern). Severe injury, disability, developmental delay, mental impairment, and death are all complications of chronic and/or severe physical abuse. Abuse victims have an increased likelihood of becoming abusers. ▪ INTERVENTIONS: Initial interventions are geared toward stabilizing injuries and preventing further abuse. If serious signs are obvious, the situation should be reported to the appropriate local sources for immediate investigation. If the child is perceived to be in immediate danger, child protection should be sought through the local child protection agency. If the signs are vague or inconsistent, observations need to be documented and reported to appropriate local sources for investigation. Long-term interventions include monitoring, therapy, and support for child and abuser(s). ▪ PATIENT CARE CONSIDERATIONS: Nurses, physicians, and other primary health care providers serve as a front-line resource for the detection and prevention of child abuse. This includes the identification of high-risk dependent child relationships, such as lack of prenatal care; previous history of child abuse or neglect; prior removal of other children from the home; parents with a history of substance abuse, depression, or other psychiatric illness; parents with a history of domestic violence; parents who were themselves abused as children; lack of adequate support networks or resources; and infants or children with high care demands. The provider needs to do a thorough assessment for signs of abuse or neglect, monitor parent-child interactions, and report any suspicions through appropriate channels. The nurse is also instrumental in the institution of actions, such as parenting classes, home visits, early intervention, support groups for parents, and counseling to prevent or halt abuse. Social agency referrals should be made for financial assistance, food, clothing, and shelter needs. Education centers on teaching about realistic expectations for child behavior at various stages of development, and about appropriate forms of discipline and on providing information on available community resources, such as Parents Anonymous or Parents United International.
