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The red flags of child abuse

Perkins, Amanda MSN, RN

doi: 10.1097/01.NME.0000529946.76463.6b
Feature: CE Connection

Many nurses will encounter children who are being abused. By identifying signs and symptoms—and reporting them—we can help prevent future occurrences.

Many nurses will encounter children who are being abused. By identifying signs and symptoms—and reporting them—we can help prevent future occurrences.

Amanda Perkins is an Assistant Professor of Nursing at Vermont Tech in Randolph, Vt., and a Nursing made Incredibly Easy! Editorial Board Member.

The author and planners have disclosed no potential conflicts of interest, financial or otherwise.



According to the CDC, in 2015, 683,000 children living in the United States were victims of abuse; 1,670 of them died as the result of abuse. Other CDC data show that one out of four children have experienced abuse in their lifetime. These numbers are unacceptable, demonstrating that we need to take action. Children who've been the victims of abuse may have mental health and social development difficulties lasting their entire lives. Additionally, these individuals have an increased incidence of risk-taking behaviors, such as smoking, drug use, and unsafe sexual practices that can persist throughout their lifetime.

This article provides information about child abuse, including types of abuse, risk factors, signs and symptoms, responses based on developmental level, complications, reporting, and your role in patient care.

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Perpetrated by a parent, caregiver, or someone in a custodial role, child abuse results in harm, potential harm, or the threat of harm to a child under age 18. In the United States, there are four recognized types of child abuse: physical, sexual, psychological/emotional, and neglect. Out of these four types, neglect is the most common, followed by physical abuse. Depending on the state, substance abuse by parents or caregivers may be considered a form of abuse (see Substance abuse). Although these types of abuse can occur separately, in most cases two or more types will occur together. In general, younger children, specifically those age 1 or younger, have higher rates of fatal abuse and neglect than children in other age groups, according to the National Children's Alliance (NCA).

Physical abuse is the infliction of physical harm, such as hitting, whipping, pinching, biting, punching, pushing, shaking, burning, or poisoning. Although the individual harming the child may not have intended to do so, it's still considered to be abuse, regardless of the intent. Physical abuse may involve objects such as belts, cigarettes, wire hangers, and whips. Shaken baby syndrome is also considered physical abuse (see Shaken baby syndrome).

Sexual abuse is inducing or coercing a child to participate in sexual acts, such as fondling and penetration. Indecent exposure and exploitation through pornographic activities are also considered to be sexual abuse.

Emotional abuse is harming a child's self-worth and emotional well-being without physically harming them. Emotional abuse includes name calling, shaming, rejection, and withholding love. Children who've been emotionally abused will feel unloved or unwanted, which can damage the child's emotional development and lead to lifelong problems.

Neglect is failure to meet a child's basic needs, including physical and emotional needs, housing, food, clothing, education, and medical care. Failure to adequately supervise children can be considered neglect, especially in children younger than age 12. In many states, failure to seek medical care for a child due to religious beliefs isn't considered to be a form of child abuse.

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Risk factors

Nurses who care for children need to be aware of factors that increase the risk of child abuse, in addition to protective factors that decrease the risk, as we outline areas to focus on when working to prevent child abuse.

Risk factors associated with child abuse include:

  • lack of knowledge about child development
  • lack of knowledge about how to care for children
  • insufficient money/income to support the needs of a child
  • substance abuse
  • psychological problems
  • unbalanced family relationships
  • domestic violence
  • single parenting.

The risk of child abuse is increased if a child's parents are young and immature, with unrealistic expectations. Parents who are young and immature may lack knowledge about child development and how to take care of children, as well as the cost of raising a child, leading to unrealistic expectations. These parents may become frustrated when their expectations aren't met.

Families with children who are premature, chronically ill, or who have attention-deficit hyperactivity disorder or a mental health disorder are also at a higher risk for child abuse. These children will have more care requirements, potentially leading to burnout and increasing the risk of abuse.

Lastly, families in which there's a nonbiological father or maternal boyfriend have an increased risk of sexual abuse.

Protective factors that can decrease the risk of child abuse include:

  • supportive family environments
  • supportive social networks
  • parental employment
  • adequate housing
  • access to healthcare.
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Signs and symptoms

A variety of signs and symptoms are associated with child abuse, including physical signs and emotional symptoms, and certain family dynamics. Children who are abused may display physical or psychological symptoms, or a combination of both. These individuals may experience lifelong complications as a result of the abuse. The signs and symptoms associated with child abuse often differ depending on the type of abuse, although overlap may occur.

The signs and symptoms that may be observed if a child is physically abused include:

  • new and healing lacerations, abrasions, and bruises
  • burns
  • fractured bones
  • dislocations
  • welts
  • submersion injuries, such as drowning or near drowning
  • injuries that mirror the shape of an object
  • acting out with aggressive behaviors
  • fear of going home
  • wariness of adults or caregivers.

A child who's sustained a traumatic brain injury as the result of physical abuse may have retinal hemorrhages and/or central nervous system injury.

Signs and symptoms of sexual abuse include:

  • inappropriate interest in sexuality or knowledge of sexuality that's beyond the child's developmental level
  • difficulty with peer relationships
  • sudden changes in behavior
  • changes in school performance
  • recurrent urinary tract infections
  • sexually transmitted infections
  • enuresis
  • redness and swelling of genitalia
  • difficulty walking or sitting comfortably
  • pregnancy or substance abuse in young adolescents
  • running away from home
  • suicide attempts.

The behavioral changes that may be seen in children who've been sexually abused include regression, acting out, and sexual behavior. Emotional abuse can lead to apathy, depression, hostility, and difficulty concentrating.

Signs and symptoms associated with neglect include:

  • inappropriate clothing for the time of year
  • poor hygiene
  • hunger
  • poor growth patterns
  • developmental delays
  • lack of supervision.

In addition to the signs and symptoms observed in children who are victims of abuse, there are also signs that you may observe in the parent or caregiver. The child's parent or caregiver may display unusual behaviors related to the child's injury, such as anger, indifference, an exaggerated emotional response, and/or denial that the injury occurred. When interacting with the child and the parent or caregiver, you may observe that the two rarely touch each other, rarely look at each other, make statements that they don't like each other, and/or the child displays anger toward the parent or caregiver.

Signs and symptoms of abuse can be noted by anyone who comes in contact with a child, such as parents, teachers, and child care providers. That's why it's important to educate these individuals about the signs of abuse and what to do if abuse is suspected. It's also important to encourage parents to educate children about “good touch/bad touch”.

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Understanding developmental levels

Nurses who work with children should have a thorough understanding of growth and development because children have different needs based on their developmental level. In this section, responses to abuse are discussed according to a child's age and associated developmental level. Be aware that not all children will fit into these categories.

A through assessment can help you determine the child's developmental level. For example, some children are developmentally delayed and, as a result, their age and developmental level don't line up. If you're caring for a 14-year-old who's developmentally at the level of a 5-year-old, you need to recognize this and plan care based on the child's developmental level.

Infants to preschool-age children may respond to abuse with alterations in sleep patterns, aggressive behavior, impulsivity, separation anxiety, crying inconsolably, withdrawal, and/or regression.

School-age children may experience absenteeism from school, aggressive behaviors, nightmares, difficulties with peer relationships, and/or trouble concentrating.

Adolescents may respond with withdrawal, social isolation, substance abuse, attempts to run away from home, peer violence, absenteeism from school, depression, and anxiety.

Understand that adolescents are more likely to be sexually abused than children in the other developmental categories. Adolescents with developmental disabilities are at the highest risk for sexual abuse. If sexually abused, boys have a lower likelihood of reporting the abuse than girls. Due to this, you need to use excellent assessment skills to identify boys who may be victims of sexual abuse.

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Associated complications

Early recognition and treatment are essential to minimize or prevent the long-term complications associated with abuse. Children who've been abused may experience:

  • depression
  • poor self-image
  • anxiety disorders
  • eating disorders
  • cognitive disorders
  • criminal behavior
  • substance abuse
  • unsafe sexual practices
  • difficulty with impulse control
  • increased suicide rates
  • poor physical health
  • posttraumatic stress disorder
  • flashbacks and/or nightmares
  • difficulty sleeping.

Abuse can also lead to toxic stress, which can cause changes during early brain development and harm to the child's nervous and immune systems.

Research has shown that individuals who were abused as children have continuing problems with life opportunities, such as educational attainment, employment, and income. These individuals have an increased risk of violence, unhealthy relationships, and poor health and wellness. Abused children have a higher risk of becoming abusive parents, leading to a cycle of abuse.

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In the United States, nurses are mandatory reporters of child abuse. This means that we can't be held liable for reports of abuse but may incur legal consequences, such as nursing license loss, for failure to report suspected abuse. Reporting includes notifying child protective services (CPS) and/or law enforcement officials. If you suspect child abuse, you'll need to call CPS and/or law enforcement, and send them a written report. Within healthcare organizations, there should be a policy and procedure outlining appropriate steps and those within the organization who need to be notified. Whenever child abuse is suspected, it's important to act quickly to ensure the safety of the child. You may be hesitant to report suspected cases of abuse, but remember that reporting isn't an accusation; it's a request for an investigation and assessment.

In 2010, medical professionals as a whole reported only 8.5% of suspected abuse cases. Failure to notice signs and symptoms of abuse can lead to far-reaching complications for the child and, in some instances, death. It's believed that failure to report suspected abuse can stem from the following:

  • lack of training and knowledge about reporting requirements
  • inability to distinguish discipline from abuse
  • lack of knowledge about the signs and symptoms of abuse
  • belief that someone else will report the abuse
  • fear of legal consequences
  • fear of the loss of a therapeutic relationship with the child's family
  • belief that CPS won't be able to help the child and family.

Lack of reporting can also occur due to biases on the part of the nurse, such as being less likely to report families who are well dressed, have good healthcare insurance coverage, and appear to be friendly. On the other hand, nurses may be more likely to report individuals who are poor, members of a minority group, or those who are underinsured/uninsured.

A child reporting abuse should always be taken seriously and all suspected cases of child abuse need to be reported. If a report is made about suspected child abuse, you're responsible for explaining the reporting process to the family/caregiver. This includes information about what to expect during the process and where they can find additional information. Provide emotional support as needed. In general, it's best practice to be honest with the family/caregiver and notify them of your intent to report. In rare instances, it may be determined that notifying the family/caregiver places others in danger. In these cases, notification shouldn't occur.

Once a report is made, the child will be evaluated for both physical and emotional findings associated with abuse. A variety of healthcare providers can evaluate the child, including nurse clinicians. The assessment process for abuse may include a patient history, physical exam, mental health evaluation, and imaging studies.

A report of child abuse may result in involvement of the court system. This typically occurs when the child has been removed from the home or is at risk from being removed from the home. In many cases, children will be allowed to stay in the home if services can be provided to the child and family. Most cases of child abuse don't result in a child being removed from the home. When a child is removed from the home, a legal guardian may assume his or her care. A legal guardian is an adult who the court has appointed to take responsibility and authority for the child. The appointment of a legal guardian doesn't result in the termination of parental rights; whenever possible, the goal is to reunite the child and family.

In some instances, death may occur as the result of child abuse. If this happens to a child for whom you're caring, it's essential to know your facility's policies and procedures, as well as state laws. Ensure that your documentation is complete, accurate, and objective. Remember that documentation of suspected abuse or abuse is essential in all circumstances, not only when death occurs. Lastly, practice good self-care to prevent burnout.

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Patient care

Patient care for the child who's been abused varies depending on his or her age, injuries, and emotional state. To gain the child's trust before beginning your assessment, speak with him or her for a few minutes followed by conducting the assessment from the periphery in. For example, begin by assessing the child's fingers and toes before listening to his or her heart or examining the chest or back.

In addition to conducting a thorough assessment, address the child's physical and psychological needs. Treat pain, burns, lacerations, and fractures accordingly. When addressing psychological needs, provide emotional support, assist with coping strategies, and help the child feel safe.

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Support programs

It's important to know the available social support programs for children and families. In many instances, these programs help keep children and families together. For example, the NCA worked with the National Child Traumatic Stress Network to develop a training series made up of 10 modules focusing on the evaluation and management of mental health services for abused children and their families.

The National Children's Advocacy Center is another organization providing free support and information for children and families. Advocates, such as a caseworker, ensure that the child's voice is heard. If a child abuse case results in court proceedings, an advocate provides support before, during, and after the proceedings. Caseworkers also provide children and families with referrals to other resources, as needed. Individual and group therapeutic services are offered to help families rebuild. In many instances, these services are for children and nonoffending family members.

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Looking ahead

Child abuse is a significant health problem that needs to be addressed by healthcare professionals. Problems associated with abuse can be long term; in some cases, spanning generations. Nurses can play an important role in health promotion, violence prevention, and the identification of warning signs and predisposing factors. With a focus on education and support, we can create long-lasting and positive changes for children.

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Shaken baby syndrome

A form of physical abuse, shaken baby syndrome is caused by shaking an infant. The average age of children experiencing shaken baby syndrome is 3 to 8 months. A parent or caregiver may shake an infant out of frustration. In many instances, the frustration stems from the child crying. Shaken baby syndrome leads to traumatic brain injury and, in some cases, death. Traumatic brain injury can lead to permanent brain damage. Nurses can educate parents and caregivers about effective coping strategies, which can potentially decrease the incidence of shaken baby syndrome.

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Substance abuse

In the following instances, substance abuse may be considered a form of child abuse:

  • prenatal exposure to illegal drugs or other substances
  • manufacturing methamphetamine with a child present
  • selling, distributing, or giving drugs (prescription or illicit) and/or alcohol to children
  • using controlled substances that impair the ability to care for children.
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consider this



You're working on a pediatric unit in a community hospital when a 3-year-old boy is transferred to your unit from the ED. The child is well-known at the hospital, having been seen in the ED for suspicious injuries on multiple occasions. The transferring nurse reports that the child was found wearing only a diaper in the middle of a busy intersection 1 mile from his home. Initial assessment revealed no life-threatening injuries. The ED nurse reports that she wasn't able to complete a more thorough assessment because the child's mother came to the ED in an impaired state. According to the nurse, the mother is a known opioid abuser and was belligerent in the ED. For the safety of the child, he was transferred to the pediatric unit for further assessment and care.

Your assessment of the child reveals abrasions on his feet, legs, and arms. You also observe bruises of various ages on the child's upper arms and back. A full body X-ray is ordered, which reveals no new fractures but three healed fractures. You notify the hospital's social services department and a nurse is sent to the unit. The social services nurse calls CPS and completes a child abuse report. Per CPS, the child is to have no contact with his mother; a foster family will be arranged to maintain the child's safety. The foster parents will visit the child throughout his stay at the hospital to gain trust and build a relationship.

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cheat sheet

Red flags



  • Inappropriate reaction to injury
  • Extreme anxiety
  • Fear of being touched
  • Atypical response to parental separation
  • Parental delay in seeking care for an injury
  • Incongruence between the description of how an injury occurred and the injury itself
  • Repeated visits to the ED
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on the web



American Psychological

Child Welfare Information


Medline Plus:

National Child Traumatic Stress

National Children's Advocacy

National Children's

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American Academy of Child and Adolescent Psychiatry. Child abuse: the hidden bruises.
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