Child Abuse

The following lists of physical and behavioral indicators suggest signs of possible child abuse for you to consider in evaluating a situation, especially if you need to decide whether to file an official report of child abuse or neglect. Indicators need to be evaluated in the context of the child’s environment because the presence of one or more of these symptoms does not necessarily prove abuse. These lists are examples and are not all-inclusive; it is also important to become familiar with the definitions and requirements contained in your state’s applicable laws.

Physical and Behavioral Indicators

Physical indicators

• Bruises and welts on the face, lips, mouth, torso, back, buttocks, or thighs in various stages of healing
• Bruises and welts in unusual patterns reflecting the shape of the article used (eg, electric cord, belt buckle) or in clusters indicating repeated contact
• Bruises on infant, especially facial bruises
• Subdural hematomas, retinal hemorrhages, internal injuries
• Cigarette burns, especially on the soles, palms, back, or buttocks
• Immersion burns (sock-like, glove-like, doughnut-shaped) on buttocks or genitalia
• Burns patterned like an electric element, iron, or utensil
• Rope burns on arms, legs, neck, or torso
• Fractures of the skull, nose, ribs, or facial structure in various stages of healing
• Multiple or spiral fractures
• Unexplained (or multiple history for) bruises, burns, or fractures
• Lacerations or abrasions to the mouth, frenulum, lips, gums, eyes, or external genitalia
• Bite marks or loss of hair
• Speech disorders, lags in physical development, ulcers
• Asthma, severe allergies, or failure to thrive
• Consistent hunger, poor hygiene, inappropriate dress
• Consistent lack of supervision, abandonment
• Unattended physical or emotional problems or medical needs
• Difficulty in walking or sitting
• Pain or itching in the genital area
• Bruises, bleeding or infection in the external genitalia, vaginal, or anal areas
• Torn, stained, or bloody underclothing
• Frequent urinary or yeast infections
• Venereal disease, especially in pre-teens
• Pregnancy
• Substance abuse—alcohol or drugs
• Positive test for presence of illegal drugs in the child’s body

Behavioral indicators

• Afraid to go home; frightened of parents
• Alcohol or drug abuse
• Apprehensive when children cry, overly concerned for siblings
• Begging, stealing, or hoarding food
• Behavioral extremes, such as aggressiveness or withdrawal
• Complaints of soreness, uncomfortable movement
• Constant fatigue, listlessness, or falling asleep in class
• Delay in securing or failure to secure medical care
• Delinquent, runaway, or truant behaviors
• Destructive, antisocial, or neurotic traits, habit disorders
• Developmental or language delays
• Excessive seductiveness or promiscuity
• Extended stays at school (early arrival and late departure)
• Extreme aggression, rage, or hyperactivity
• Fear of a person or an intense dislike of being left with someone
• Frequently absent or tardy from school or drops out of school or sudden school difficulties
• History of abuse or neglect provided by the child
• Inappropriate clothing for the weather
• Massive weight change
• Indirect allusions to problems at home such as “I want to live with you”
• Lack of emotional control, withdrawal, chronic depression, hysteria, fantasy, or infantile behavior
• Lags in growth or development
• Multiple or inconsistent histories for a given injury
• Overly compliant, passive, undemanding behavior; apathy
• Poor peer relationships; shunned by peers
• Poor self-esteem, self-devaluation, lack of confidence, or self-destructive behavior
• Role-reversal behavior or overly dependent behavior; states there is no caretaker
• Suicide attempts
• Unusual interest in or knowledge of sexual matters, expressing affection in inappropriate ways
• Wary of adult contacts, lack of trust, uncomfortable with or threatened by physical contact or closeness

Perpetrator Behaviors with Children

Indicative actions by an abusive adult can take many forms and the lists below are only a sample. Sometimes the abuser’s behavior will be a clue as to what type of abuse they are engaged in.

Where physical abuse is happening, the adult abuser may:

• Have unrealistically high standards and expectations for self and children
• Have an undue fear of spoiling the child
• Consistently react to the child with impatience or annoyance
• Be overly critical of the child and seldom discuss the child in positive terms
• Lack understanding of the child’s physical and emotional needs, or their developmental capabilities
• Be incapable of child rearing
• Believe in the necessity of harsh physical discipline
• Be rigid or compulsive; hostile and aggressive; or impulsive with poor emotional control
• Be authoritative and demanding, or fear or resent authority
• Lack control or fear losing control
• Be cruel or sadistic
• Be irrational
• Accept violence as a viable means of problem resolution
• Be reluctant or unable to explain the child’s injuries or condition or give explanations which are farfetched or inconsistent with the injury
• Over or under react to the child’s injury
• Not consent to diagnostic studies of the child
• Have the child treated by a different hospital or physician each time the child needs medical attention
• Fail to keep appointments
• Trust no one; feel alone, without friends or support; or view seeking or accepting help as a weakness
• Be under pressure
• Have an emotionally dependent spouse; be engaged in a dominant-passive marital relationship; or have other marital problems
• Have been physically abused himself/herself

Where sexual abuse is happening, the adult abuser may:

• Be overly protective of the child
• Refuse to allow the child to participate in social activities
• Be jealous of the child’s friends or activities
• Accuse the child of promiscuity
• Distrust the child
• Have marital problems
• Need to be in control or fear losing control
• Be domineering, rigid, or authoritarian
• Favor a “special” child in the family
• Have been sexually abused himself/herself

Where emotional maltreatment is happening, the adult abuser may:

• Act irrationally or appear to be out of touch with reality
• Be deeply depressed
• Exhibit extreme mood swings
• Constantly belittle the child or describe the child in terms such as “bad,” “different,” or “stupid”
• Be cruel or sadistic
• Be ambivalent towards the child
• Expect behavior that is inappropriate to the child’s age or developmental capabilities
• Consistently shame the child
• Threaten the child with the withdrawal of love, food, shelter, or clothing
• Consistently threaten the child’s health or safety
• Reject the child or discriminate among children in the family
• Be involved in criminal activities
• Use bizarre or extreme methods of punishment
• Avoid contact with the child, seldom touching, holding, or caressing him/her
• Avoid looking or smiling at the child
• Be overly strict or rigid
• Torture the child
• Physically abuse or neglect the child
• Have been abused or neglected himself/herself

Where neglect is happening, the neglecting adult may:

• Be apathetic
• Have a constant craving for excitement and change
• Express dissatisfaction with his/her life
• Express desire to be free of the demands of the child
• Lack interest in the child’s activities
• Have a low acceptance of the child’s dependency needs
• Be generally unskilled as a parent
• Have little planning or organizational skills
• Frequently appear unkempt
• Perceive the child as a burden or bother
• Be occupied more with his/her problems than with the child’s
• Be overly critical of the child and seldom discuss him/her in positive terms
• Have unrealistic expectations of the child, expecting or demanding behavior beyond the child’s years or ability
• Seldom touch or look at the child
• Ignore the child’s crying or react with impatience
• Keep the child confined, perhaps in a crib or playpen, for long periods of time
• Be hard to locate
• Lack understanding of the child’s physical or emotional needs
• Be sad or moody
• Fit the clinical description “passive and dependent”
• Lack understanding of the child’s developmental capabilities
• Fail to keep appointments and return telephone calls
• Have been neglected himself/herself (Clermont County Ohio CPS, 2019)

Dependent Adult Abuse

When evaluating a situation for potential abuse, be alert to behaviors of both the victim and the abuser that signal possible abuse or other serious problems. These behaviors may occur in the absence of abuse but their presence warrants consideration of the possibility of abuse.

Abuser Behaviors

• Victim not allowed to speak for himself or herself
• Obvious absence of assistance
• Indifference or anger toward victim
• Blames the victim
• Aggressive behavior
• Previous history of abuse to others
• Problems with alcohol or drugs
• Flirtations, coyness, etc.
• Conflicting accounts of incidents by the family, supporters, victim
• Noncompliance with service providers in planning for care and implementation
• Withholding of security and affection

Perpetrators frequently groom their targets before assault, gaining trust, testing the waters to see how the person will react. Indicators of grooming include showing special interest in the person, gifts, touching, massage, setting up time to be alone (bathing in the late evening, providing transportation).

Dependent Adult Behaviors

• Fear or reluctance to openly talk with others
• Withdrawal or quiet/subdued, depressed mood
• Depression, either acute or situational, that is uncharacteristic of the person’s past behavior
• Helplessness or resignation, an “I don’t care” attitude, too accepting of their perceived fate/future
• Hesitation to talk openly, reluctant to discuss their well-being, change the subject to non-threatening issues
• Implausible stories (not related to dementia), explanations that don’t match up with facts or visible circumstances
• Confusion or disorientation (not related to dementia), difficulty in expressing thoughts, appears distracted
• Ambivalence/contradictory statements, fails to show concern about personal events, unable to repeat the same explanation of events or circumstances
• Anger, displayed toward you, family/friends, or toward everyone and everything
• Non-responsiveness, refuses to answer questions appropriately
• Agitation/anxiety, becomes increasingly agitated or anxious when you are there

Indicators of Physical Abuse

The presence of a single indicator may not raise suspicion of abuse, but a combination of indicators may reveal a serious situation. The concerned observer may want to question further, document the situation for future use, or make a report.

Examples of physical abuse in society

• Injury that has not been properly cared fo
• Any injury incompatible with history
• Pain on touching
• Cuts, lacerations, or puncture wounds
• Dehydration and/or malnourishment
• Pallor
• Sunken eyes, cheeks
• Evidence of inadequate care
• Eye problems, retinal detachment
• Poor skin hygiene
• Absence of hair or hemorrhaging below scalp
• Soiled clothing or bed
• Burns
• Locked in a room
• Evidence of unset bones
• Heavy or excessive medication

Examples of physical abuse by staff

• Unauthorized use of physical or chemical restraints
• Administration of medications or enforced isolation as punishment or simply for convenience
• Use of substitute treatment in conflict with a physician’s order

Dating of bruises

• Physicians and law enforcement disagree about the validity of dating of bruises. However, they do agree that bruises change color as the injury ages and the simultaneous presence of bruises of various colors on the same person indicates separate injuries.

Indicators of Sexual Abuse

Some of these indicators include the following:

• Person’s behavior changes drastically, e.g., acting out, angry, lashing out, inappropriate affect.
• Person is depressed or shows symptoms of other mental health issues.
• Person acts afraid in the presence of the caretaker.
• Person does not want to be left alone with the caretaker.
• Genital or anal bruises
• Vaginal or anal bleeding
• Swelling or redness of genital area
• Venereal disease

Elders and people with disabilities may be targeted by sexual predators due to their vulnerability. Most people with developmental disabilities have had no sex education. More than 80% of women and more than 30% of men with developmental disabilities have experienced sexual assault. Nearly three-quarters of women with disabilities have been violently victimized sexually at some point in their lives.

Sexual assault is not spontaneous or accidental, but communities tend to blame the survivors. It is often treated as a scandal, an internal personnel matter, or a public relations problem. Although most of the victims are female, there are also male victims.

Frail elders too often lack a strong support system, which makes them more vulnerable to abuse. Their beliefs about sexual abuse increase feelings of shame and guilt.

Sexual abuse differs with age or frailty

• May complicate an existing illness
• Involves a longer recovery time to deal with abuse
• Increases the chance of sustaining serious injury
• May cause genital tearing and bruising
• May fracture pelvis or hip bones
• Increases the risk of infections

Indicators of Financial Exploitation

The act or process of taking unfair advantage of a dependent adult or a dependent adult’s physical or financial resources for one’s own personal or pecuniary profit, without the informed consent of the dependent adult—including theft, by the use of undue influence, harassment, duress, deception, false representation, or false pretenses as a result of the willful or negligent acts or omissions of a caretaker.

Indicators

• Dependent adult is inaccurate, confused, or has no knowledge of finances
• Disparity between income/assets and lifestyle or living arrangement
• Caretaker expresses unusual interest in the amount of money spent for care of the dependent adult
• Unpaid bills when resources should be adequate
• Caretaker is evasive about financial arrangements
• Signatures on checks don’t match dependent adult’s signature
• Unusual activity in bank accounts
• Dependent adult turns over financial affairs to someone in exchange for lifelong care, but does not appear to have basic necessities such as food and shelter
• Caretaker begins to handle the dependent adult’s financial affairs without his or her presence or without consultation

Examples

• Misuse of power of attorney or conservatorship
• Identity theft
• Scams
• Coercion into signing or changing legal documents
• Taking or misusing a dependent adult’s property, money, social security or pension check, food stamps, medication, or others

Indicators of Denial of Critical Care (Neglect)

Denial of critical care (neglect) is defined as the deprivation of the essential minimum food, shelter, clothing, supervision, physical or mental health care, and other care necessary to maintain a dependent adult’s life or health, as a result of the willful acts or negligent acts or omissions of a caretaker.

Indicators

• Pattern of failure to provide adequate food; malnourishment; or contaminated or spoiled food in home
• Lack of adequate clothing to provide protection from the weather
• Lack of heat in winter or lack of air conditioning or fans in summer; unsanitary or hazardous conditions
• Refusal to provide medical evaluation for condition detected by medical personnel
• Failure to follow through with medical treatment plan recommended by health professional
• Unable to manage affairs because of confusion and deterioration
• Leaving dependent adult who is incapable of self-supervision without a responsible caretaker
• Knowingly selecting an inappropriate caretaker
• Abandonment

Examples

• Withholding of care, medication, food, liquids, assistance with hygiene, etc.
• Failure to provide physical aids such as eyeglasses, hearing aids, false teeth
• Failure to provide safety precautions and access to care

Indicators of Denial of Critical Care (Self)

Note: Not all states define separate neglect/denial of care in exactly the same way but it is important to understand the general distinctions.

Denial of Critical Care (Self) is the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult’s life or health, as a result of the acts or omissions of the dependent adult.

Indicators

• Failure to provide adequate food, shelter or clothing
• Intentional physical self-abuse
• Suicidal statements
• Refusal of medical treatment or medication (refusal not based on religious grounds)
• Refusal of services that might alleviate the situation, when once would have accepted
• Refusal of visitors
• Denial of obvious problems

Examples

• Unable to prepare food or obtain groceries
• Unable to care for self
• Confused and unable to understand living conditions
• Holes in the floors and walls of home
• Home is cluttered with garbage (health hazard)

What Is Not Abuse

There are situations that may appear to be dependent adult abuse but may not be according to individual state statutes. Some of these situations include:

• Refusal or deprivation of medical treatment based on religious beliefs. The practices and beliefs of some religions call for reliance on spiritual means for healing rather than medical treatment.
• Withholding, withdrawing, or refusing medical treatment based on terminal illness. State laws will specify from whom requests can come and may include: the dependent adult, their next-of-kin, attorney-in-fact (power of attorney), or guardian.
• Domestic abuse situations where the victim is not dependent as defined in law.
• People incarcerated in a penal setting.
• Lack of means or access to means for providing care.