Indicators, or signs, of child abuse or maltreatment are physical or behavioral acts that cause you to be concerned about the presence of abuse. When evaluating a situation to determine if there is reasonable cause to suspect child abuse or maltreatment/neglect based on injuries to the child:

• Know the likely areas for normal versus suspicious injuries.
• Consider the size and shape of the injury.
• Consider the child’s developmental stage and related likely injuries.

Accidental childhood injuries usually involve bony areas such as shins, elbows, and knees. Toddlers learning to walk often fall and skin or bruise these areas, just as older children may do the same thing while learning to ride a bicycle. Suspicious injuries usually occur in areas that are not susceptible to accidental injuries, given the age of the child, and may include the back, buttocks, and backs of thighs or calves.

If an injury was serious but appropriate treatment was delayed or omitted, especially in a case where the mechanism of injury does not match the injuries as seen, there may be reasonable cause to suspect child abuse or maltreatment/neglect.

Do not view indicators in isolation. Each indicator must be considered in relation to the child’s current age and circumstances and in the context of their physical condition or behavior. You may need to assess if there is an explanation for the presenting concern and whether the explanation is consistent with the observed physical and behavioral indicators.

Abuse or maltreatment should never be assumed. Consider your prior experiences with this child and whether there is a difference in what you are currently observing. It is important to make an objective assessment that is free from any implicit or explicit bias.

8.1 Indicators of Physical Abuse

8.1.1 Physical Indicators of Physical Abuse

[The following material is from NYSOCFS, 2020, unless otherwise cited.]

Physical indicators of child maltreatment and abuse include unexplained bruises, fractures, burns, welts or lacerations or suspicious injury or bruising including where:

• the location of the injury may be atypical
• the explanation provided for the injury doesn’t match the pattern of injury
• the bruise or laceration is shaped like an object (such as a handprint or looped cord)

Unattended physical problems, medical or dental needs, pain or itching in the genital area, and lags in physical development or growth are also physical indicators of child maltreatment and abuse.

Unexplained bruises and welts can be strong indicators of child abuse. When doing a physical exam, note bruises or welts on the face, lips, mouth, torso, back, buttocks, or thighs—especially in various states of healing.

Bruises that are clustered, form regular patterns, or reflect shape of article used to inflict, such as an electric cord or belt buckle are cause for concern. Also consider bruises that regularly appear after absence, weekend, or vacation.

Unexplained burns are another cause for concern. Cigars or cigarettes can be used to create burn patterns on a child’s soles, palms, back, and buttocks. Burns in sock-like, glove-like, or doughnut-shaped patterns on buttocks or genitalia (immersion burns), or patterned burns from an electric burner or iron, as well as rope burns on arms, legs, neck, or torso are indicators of abuse.

Unexplained lacerations or abrasions to a child’s mouth, lips, gums, eyes, ears, or external genitalia are also indicators of abuse. Consider lacerations on the backs of a child’s arms, legs, or torso, human bite marks, or frequent injuries that are “accidental” or unexplained.

8.1.2 Behavioral Indicators of Physical Abuse

Both children and adults often exhibit behaviors that can indicate the presence of abuse. A child may be wary of adult contact, frightened of parents or afraid to go home. They may be apprehensive or nervous when they hear other children cry and may exhibit extremes of behavior such as aggressiveness, withdrawal, or sudden changes in behavior.

Some children try to hide injuries by wearing long-sleeved shirts or pants or similar clothing. Others may have difficulties with emotional boundaries or seek inappropriate affection from an adult.

Parents and caregivers also often engage in behaviors that can indicate the presence of abuse. They may seem unconcerned about the child, attempt to conceal the child’s injury, or take an unusual amount of time to obtain needed medical care. They may offer an inadequate, inconsistent, or inappropriate explanation for the child’s injury. To conceal the abuse, they may take the child to a different doctor or hospital for each injury.

Adults who abuse children often have poor impulse control and may also have a personal history of abuse as a child. They may have a history of abuse of alcohol or other drugs or a history of mental illness. An adult may discipline the child too harshly considering the child’s age or what they did wrong or describe the child as bad, evil, etc.

8.2 Maltreatment or Neglect

8.2.1 Physical Indicators of Maltreatment or Neglect

For children who are experiencing maltreatment or neglect, certain physical indicators may be present. They may be consistently hungry, have poor hygiene, or dress inappropriately. They often have unmet physical problems or medical or dental needs. These children often experience a lack of supervision for long periods of time. They may be left overnight or even abandoned.

8.2.2 Behavioral Indicators of Maltreatment or Neglect

For children experiencing maltreatment of neglect, certain behavioral indicators are present. They may state they have no caretaker and may beg for or steal food. They are often tired and fatigued and fall asleep in class. School attendance may be infrequent, or conversely, a child may try to stay in school, arriving early and staying late. Be aware of signs of alcohol and drug abuse.

For a parent or guardian, behavior indicators of neglect or maltreatment of a child include misuse alcohol or other drugs, evidence of limited intellectual capacity, a history of neglect as a child, or exposing the child to unsafe living conditions.

The parent may have a disorganized home life, be isolated from friends, relatives, and neighbors, and feel as though nothing will change. Be aware if the parent or caregiver has a long-term chronic illness. In some instances, the parent or caregiver is completely absent or cannot be found.

8.3 Emotional Maltreatment

8.3.1 Physical Indicators of Emotional Maltreatment

For children, physical indicators of emotional maltreatment overlap with other indicators. Physically, a child may lag in physical development and exhibit a failure to thrive.

Certain disorders are common in children experiencing emotional maltreatment:

• Conduct disorders (fighting in school, anti-social, destructive behaviors)
• Habit disorders (rocking, biting, sucking fingers)
• Neurotic disorders (tics, sleep problems, inhibition of play)
• Psychoneurotic reactions (phobias, hysterical reactions, compulsion, hypochondria)

8.3.2 Behavioral Indicators of Emotional Maltreatment

For a child, emotional maltreatment can cause mental and emotional developmental delays. Look for overly adaptive behaviors such as inappropriately adult or inappropriately infantile behavior. A child may exhibit extremes of behavior (compliant, passive, aggressive, demanding). Suicide attempts or gestures and self-mutilation are common.

In adults, behavioral indicators of emotional maltreatment of a child may be obvious to a healthcare provider. The adult may treat children in the family unequally or blame or belittle the child—even in public.

An adult may be cold and rejecting and not seem to care much about the child’s problems. Emotionally controlling adults often exhibit inconsistent behavior toward the child.

8.4 Sexual Abuse

Under New York Penal Law, sexual abuse is a considered to be a form of abuse or maltreatment. Sexual abuse by an adult involving a child is described as sexual misconduct, persistent sexual abuse, forcible touching, incest, rape, facilitating a sex offense with a controlled substance, or encouraging a child to engage in any act that would render a child a victim of sex trafficking.

Sexual abuse also includes criminal sexual acts, aggravated sexual abuse, sexual conduct against a child, female genital mutilation, and promoting prostitution. The use of a child in a sexual performance, promoting an obscene sexual performance by a child, promoting a sexual performance by a child, possessing an obscene sexual performance by a child, or possessing a sexual performance by a child is considered to be sexual abuse.

8.4.1 Physical Indicators of Sexual Abuse

A child who has been sexually abused may come to the emergency department because of an injury caused by the abuse. Look for signs such as difficulty in walking or sitting, torn, stained, or bloody underclothing, pain or itching in genital area, or bruises or bleeding in external genital, vaginal, or anal areas.

Other indicators of child sexual abuse include pregnancy, especially in early adolescent years, and sexually transmitted diseases, venereal diseases, and oral infections (especially in pre-adolescent age group). 

8.4.2 Behavioral Indicators of Sexual Abuse

For children, there are a number of behavioral indicators of sexual abuse. Some may be obvious while others are more subtle. For example, a child may directly report a sexual assault by caretaker. They may exhibit bizarre, sophisticated, or unusual sexual behaviors or knowledge for their age. They may have an exaggerated fear of closeness or physical contact, often with the perpetrator.

Withdrawal, fantasy, or infantile behavior is often common in children who are being sexually abused. Self-injurious behaviors or suicide attempts may be the reason a child ends up in the emergency department.

Some behavioral indicators of sexual abuse may be less obvious—especially during a healthcare appointment. A child who is being sexually abused may have poor peer relationships, may be unwilling to change for, or participate in, physical education classes, exhibit aggressive or disruptive behaviors, may run away from home, or refuse to attend school.

For parents or caregivers, behaviors that indicate sexual abuse of a child are varied. They may be overly protective or jealous of child, have low self-esteem, or misuse alcohol or other drugs. Parents may be geographically isolated or lack social and emotional contacts outside the immediate family. A sexually abusive parent or caretaker may encourage the child to engage in prostitution or sexual acts in the presence of the caretaker.

Sometimes evaluating possible child abuse or maltreatment will be straightforward. For example, a baby born with a positive toxicology, a child with the handprint of a slap showing on their face, or a direct disclosure made by a child give clear support for reasonable cause to suspect. However, more often the situation will require that you pull together several indicators or clusters of indicators. Although the above lists identify many common indicators of possible abuse or maltreatment, these should not be considered in isolation from the child’s current condition or circumstances (how they look and act). In addition, signs may sometimes appear contradictory.

8.5 Child Abuse in a Virtual Setting

Technology-facilitated abuse is defined as the misuse of digital systems such as smartphones or other internet-connected devices to harm an individual. The proliferation of these devices, exacerbated by the COVID19 pandemic, has increased the risks of technology-facilitated abuse for vulnerable members of society. These forms of abuse are on the rise, with perpetrators using digital technologies such as GPS Tags and device spyware tools to monitor and control another person (Straw and Tanczer, 2023).

Victims, including children and young adults, experience a range of abuses, including general harassment, digital surveillance using spyware and tracking devices, and sextortion (having intimate images or videos shared without their consent). GPS trackers have been a growing phenomenon in domestic violence cases, including reports of trackers being placed in children’s toys and strollers. The harm from this type of abuse is significant, causing anxiety and trauma, a heightened risk for future psychological symptoms, self-injury, and suicidal ideation (Straw and Tanczer, 2023).

Online sexual abuse is very common. It is often related to unwanted sexual approaches, especially by an adult who contacts children for sexual purposes. Even if an interaction is voluntary, many users report being persuaded or coerced into sexual activity (Jonsson et al., 2019).

In a Swedish study of 14–15-year-old children, sexual approaches were experienced more often by girls than boys and were also more common among older adolescents and those defining themselves as gay, bisexual, or as being unsure about sexual orientation. The group most vulnerable to sexual approaches and grooming tend to consist of high-risk youths with a prior history of sexual abuse. Individuals who use chatrooms, communicate with people online, engage in sexual behavior online, and share personal information online are also at risk (Jonsson et al., 2019).

Common online behaviors that can lead to abuse include sharing contact information, looking for someone to talk to about sex (or have sex with), sending nude pictures, and posting nude pictures on a community or internet site. Because of this, healthcare providers working with children and young adults should screen their patients for online behavior and online abuse (Jonsson et al., 2019).