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 slightly 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 (NYSOCFS, 2023).

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.

9.1 Indicators of Physical Abuse

9.1.1 Physical Indicators

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

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.

9.1.2 Behavioral Indicators

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.

9.2 Maltreatment or Neglect

9.2.1 Physical Indicators

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.

9.2.2 Behavioral Indicators

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 feels 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.

9.3 Emotional Maltreatment

9.3.1 Physical Indicators  

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)

9.3.2 Behavioral Indicators

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 fairly 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 child’s problems. Emotionally controlling adults are often exhibit inconsistent behavior toward the child.

9.4 Sexual Abuse

9.4.1 Physical Indicators

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).

9.4.2 Behavioral Indicators

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.