An indicator is an alert or warning that you need to give more attention to a situation. Indicators of abuse can be obvious: for example, a child with the mark of a belt showing on his or her back or burns in the shape of an iron or cigarette tip gives clear support for reasonable cause to suspect child abuse. Often, however, your suspicion will rest on less obvious physical or behavioral indicators.
Indicators must always be considered within the context of how a child behaves, how he or she looks, what you know about the child, and the child’s family situation and history. Children do not react the same way to similar circumstances and many abused children may not show any of the indications discussed below. Nevertheless, learning to recognize high-risk situations and the signs and symptoms of abuse is an important skill for a mandated reporter. Indicators can alert you to physical, sexual, and mental abuse or neglect.
Indicators of Physical Abuse
Indicators of physical abuse do not, in and of themselves, prove that a child has been abused. Keep in mind that injuries occur accidentally when children play. Physical abuse should be considered when the explanation does not fit the pattern or frequency of injury. When physical abuse has occurred, indicators can be behavioral as well as physical.
Physical indicators of physical abuse include:
- Unexplained injuries
- Unbelievable or inconsistent explanations of injuries
- Multiple bruises in various stages of healing
- Bruises located on faces, ears, necks, buttocks, backs, chests, thighs, back of legs, and genitalia
- Bruises that resemble objects such as a hand, fist, belt buckle, or rope
- Injuries that are inconsistent with a child’s age/developmental level
Behavioral indicators of physical abuse include:
- Fear of going home
- Extreme apprehensiveness or vigilance
- Pronounced aggression or passivity
- Flinching easily or avoiding touch
- Abusive behavior or talk during play
- Unable to recall how injuries occurred
- Account of injuries is inconsistent with the nature of the injuries
- Fear of parent or caregiver
Shaken Baby Syndrome
Shaken baby syndrome/abusive head trauma (SBS/AHT) is a special type of physical abuse. It is a term used to describe the constellation of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child.
Infants 2 to 4 months of age are at the greatest risk of injury from shaking, because their brains are softer and their skulls are thinner than those of adults. An infant’s head is also larger in proportion to its body than an adult’s head and its neck muscles, tendons, and ligaments are weaker than those of an adult.
Shaking a baby may cause bruising, swelling, and bleeding (intracerebral hemorrhage) of the brain, which may lead to permanent severe brain damage or even death. It usually occurs in children younger than 2 years old but may be seen in children up to the age of 5 (Reilly & Martin, 2015).
There are various signs of SBS/AHT, and in less severe cases the child may not be seen by a medical professional and properly diagnosed. In most severe cases a child quickly becomes unconscious with “rapidly escalating central nervous system dysfunction.” Injuries from SBS/AHT can result in severe disability or death and if you suspect a child has been shaken you should seek immediate medical attention.
Indicators of Sexual Abuse or Exploitation
Recently in Pennsylvania the sexual abuse of children within an institutional setting has been a public concern. The hierarchical structure of institutions can give a perpetrator an easy way to exploit the dependence that often defines relationships between youth and their caregivers (Spröber et al., 2014).
In general, whether in an institution or a familial situation, victims of sexual abuse or exploitation may be threatened with negative consequences in order to keep them silent. Certain factors contribute to silence, including secrecy, helplessness, entrapment, accommodation, and the fear of not being taken seriously when revealing abuse (Spröber et al., 2014).
Despite common beliefs that sexual abusers are strangers, in more than 80% of cases the abuser is likely to know the child they are sexually abusing.
Physical indicators of sexual abuse or exploitation include:
- Sleep disturbances
- Pain or irritation in genital/anal area
- Difficulty walking or sitting
- Difficultly urinating
- Positive testing for sexually transmitted disease or HIV
- Excessive or injurious masturbation
Behavioral indicators of sexual abuse or exploitation include:
- Sexually promiscuous
- Developmental age-inappropriate sexual play and/or drawings
- Cruelty to others
- Cruelty to animals
- Fire setting
Indicators of Serious Mental Injury
Mental and emotional injury may be the most prevalent type of child abuse; however, it is also the most hidden, underreported, and least studied (Ba-Saddik & Hattab, 2012). Literature on mental and emotional injury is limited because it is the most difficult form of abuse to research, due to lack of a consistent definition, and difficulty detecting, assessing, and substantiating the abuse (Ba-Saddik & Hattab, 2012). Researchers have noted that individuals with social anxiety disorder* have higher rates of childhood emotional abuse and emotional neglect compared to healthy controls (Kuo et al., 2011).
*Social anxiety disorder: persistent fear of social or performance situations in which an individual is at risk for embarrassment, humiliation, or possible scrutiny by unfamiliar persons (Kuo et al., 2011).
Physical indicators of serious mental injury include:
- Frequent psychosomatic complaints (nausea, stomachache, headache, etc.)
- Speech disorders
Behavioral indicators of serious mental injury include:
- Expressing feelings of inadequacy
- Fearful of trying new things
- Overly compliant
- Poor peer relationships
- Excessive dependence on adults
- Habit disorders (sucking, rocking, etc.)
- Eating disorders
Indicators of Serious Physical Neglect
Physical neglect is an act of abuse. It accounts for over three-quarters of confirmed cases of child maltreatment in the United States—far more than physical or sexual abuse—but it continues to receive less attention from practitioners, researchers, and the media (CWIG, 2012).
Identifying serious physical neglect in children may seem more difficult than identifying other forms of abuse because neglect usually involves the absence of a certain behavior, rather than its presence. A thorough investigation of the child’s safety and risk followed by a comprehensive family assessment can help determine what kinds of services and supports the family may need (CWIG, 2012).
Physical indicators of serious physical neglect include:
- Lack of adequate medical and dental care
- Often hungry
- Lack of shelter
- Child’s weight is significantly lower than what is normal for his/her age and gender
- Developmental delays
- Persistent (untreated) conditions (e.g. head lice, diaper rash)
- Exposure to hazards (e.g., illegal drugs, rodent/insect infestation, mold)
- Clothing that is dirty, inappropriate for the weather, too small or too large
Behavioral indicators of serious physical neglect include:
- Not registered in school
- Inadequate or inappropriate supervision
- Poor impulse control
- Frequently fatigued
- Parentified behaviors (when children are forced to take on the role and responsibilities of a parent)
Healthcare providers must differentiate between neglectful situations and poverty. For example, if a family living in poverty was not providing adequate food for their children, it would be considered neglect only if the parents were aware of but chose not to use food assistance programs. Taking poverty into consideration can prevent unnecessary removals and place the focus on providing concrete services for families to protect and provide for their children (CWIG, 2012).
Risk Factors for Child Abuse and Neglect
Risk factors are characteristics associated with child abuse and neglect—they may or may not be direct causes. A combination of individual, relational, community, and societal factors contribute to the risk of child maltreatment. Although children are not responsible for the harm inflicted upon them, certain characteristics have been found to increase their risk of being maltreated (CDC, 2016a).
Individual Risk Factors for Victims
- Children younger than 4 years of age
- Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses) (CDC, 2016a).
Individual Risk Factors for Perpetration
- Parents’ lack of understanding of children’s needs, child development and parenting skills
- Parents’ history of child maltreatment in family of origin
- Substance abuse and/or mental health issues including depression in the family
- Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
- Non-biological, transient caregivers in the home (e.g., mother’s male partner)
- Parental thoughts and emotions that tend to support or justify maltreatment behaviors (CDC, 2016a).
Family Risk Factors
- Social isolation
- Family disorganization, dissolution, and violence, including intimate partner violence
- Parenting stress, poor parent-child relationships, and negative interactions (CDC, 2016a).
Community Risk Factors
- Community violence
- Concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates, and high density of alcohol outlets), and poor social connections (CDC, 2016a).