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Child abuse should always be suspected, especially if injuries are not consistent with the history of the chief complaint.  In order to provide optimal care to these children, it is necessary that the prehospital care provider understand general principles regarding child abuse.  The following topics will be discussed:

·                      Common characteristics of abusers

·                      Common characteristics of abused children

·                      Physical and behavioral indicators of abuse

·                      Sexual abuse

·                      Assessment skills/techniques

·                      Appropriate management of the potentially abused child


At the end of this lesson the participants will be able to:

1.                  Determine common features present in abusive situations

2.                  Describe abnormal physical findings that have a high index of suspicion for child abuse

3.                  Discuss appropriate interventions in cases of suspected child abuse


The following terms will be used during this lesson:


The following section provides information and space for taking notes on the key concepts discussed by the instructor.

General Statistics

  • At least 1-3% of American children experience child abuse/neglect 

            each year

  • Annually, approximately 1.5 million children are abused:
    • Physical- 200,000
    • Neglect-  800,000
    • Sexually-  60,000
  • Second only to SIDS, 4000 children die each year as a result of abuse

Characteristics of Abusers

  • In the majority of cases, the abuser is a:
    • Related caregiver-      90%
    • Boyfriend of mother-  5%
    • Unrelated babysitter-  4%
    • Sibling of child-          1%
  • Most abusers tend to be lonely, unhappy, angry adults under tremendous stress
  • Usually isolated, incapable of using a support system
  • Often, the abuser experienced physical or emotional abuse themselves as children
  • Mothers are more likely to physically/emotionally abuse than fathers
  • Fathers are more likely to sexually abuse than mothers
  • Abusers come from all ethnic, geographical, religious, educational, occupational, and socioeconomic groups

Characteristics of an Abused Child

  • Demanding, difficult behavior
  • Decreased level of functioning
  • Hyperactivity
  • Intellectual ability equal or above the parent
  • Usually less than 5 years of age
  • Boys are physically abused more often than girls


Contributing Factors

  • Intermittent, unpredictable abuse is more common than continuous

      physical abuse or neglect

  • Abuse is frequently precipitated by some stressor in the adult caregiver’s life, particularly when the adult expects the child to fill emotional needs created by the stress
  • Common crises which may lead to an abusive episode:
    • Financial stress
    • Loss of employment
    • Eviction from housing
    • Marital or relationship stress
    • Physical illness in a child which leads to intractable crying
    • Death of a family member
    • Diagnosis of an unwanted pregnancy

Physical Indicators

Physical findings which trigger a high index of suspicion:

  • Any obvious or suspected fractures in a child under two years of age
  • Injuries in various stages of healing, especially burns and bruises
  • More injuries than usually seen in children of the same age
  • Injuries scattered on many areas of the body
  • Bruises or burns in patterns that suggest intentional infliction
  • Increased intracranial pressure in an infant
  • Suspected intra-abdominal trauma in a young child
  • Any injury that does not fit the description of the cause given

Information in the medical history which triggers a high index of suspicion:

  • A history that does not match the nature or the severity of the injury
  • Vague parental accounts or accounts that change during the interview
  • Accusations that the child injured him/herself intentionally
  • Delay in seeking help
  • Child dressed inappropriately for the situation

Secondary Assessment Findings

  • Bruises
  • Welts
  • Burns
  • Subduaral hematomas
  • Abdominal injuries
  • Bone injuries

Behavioral Indicators

  • Child
    • No expectation of parental comfort
    • Overly friendly or withdrawn
  • Adult

o       May present angry, fearful, hostile, or quiet

o       Unusual parent-child interactions


Contributing Factors

  • Inattention to the basic needs of a child
  • Lack of food, medical care, shelter, education, or clothing
  • Caregiver’s misuse of drugs and alcohol
  • Child’s misuse of drugs and alcohol
  • Child abandonment

Physical Indicators

  • Underweight
  • Poor hygiene
  • Clothing soiled
  • Bald patches
  • Gross unattended dental or medical problems

Behavioral Indicators of Child

  • Dull, inactive
  • Beg for food
  • Fall asleep in class
  • Drug, alcohol addiction
  • Delinquency


Contributing Factors

  • Caregiver’s failure to provide a nurturing environment
  • Child may be blamed for events or belittled
  • Constant lack of concern for child’s welfare

Physical Indicators

  • Speech disorder
  • Failure to thrive

Behavioral Indicators of Child

  • Eating disorder
  • Phobias
  • Antisocial behavior


Contributing Factors

  • Any sexual activity between an adult and child 16 years and younger
  • Usually associated with physical/emotional abuse or neglect
  • Often, abuser experienced similar abuse as a child
  • Females are the most common victims
  • Over one-half of the victims are under 12 years of age

Types of Sexual Abuse

  • Vaginal intercourse
  • Sodomy
  • Oral-genital contact
  • Molestation (fondling, masturbation, or exposure)

KEY POINT: Due to the chronic nature of sexual abuse, only 35% will have physical findings.


Physical Indicators

  • Pregnancy
  • Venereal disease
  • Painful urination or defecation
  • Tenderness or lacerations to the perineal area
  • Bleeding from the rectum or vagina

Behavioral Indicators of Child

  • Withdrawn
  • Infantile behavior
  • Exhibit sophisticated sexual or seductive behavior
  • Change underwear often


History Collection

  • Collect information in a professional, non-judgmental manner
  • Phrase questions to parents in a non-confrontational manner
  • Ask the child open-ended questions
  • Do not press for information the child is not ready to disclose
  • Do not reveal to the parent information obtained from the child

Physical Assessment

  • Obtain consent from mentally competent children before physical examination
  • Look for injuries over entire body; complete genital exam last
  • Document findings in clear objective statements (i.e. “Palms show one centimeter circular burns” vs. “Cigarette burns to hands”)
  • Document verbatim statements made by the child or parent


Collaborative Effort

  • EMS personnel, in most states, are obligated to report suspected incidences of child abuse or neglect
  • In most states, EMS personnel are considered to be mandated reporters (they are protected from being sued for false allegations)
  • Physicians and nurses are also mandated reporters
  • If healthcare professionals ignore the written objective recorded findings from EMS personnel, criminal and civil liability may result
  • Failure for EMS personnel to report suspected child abuse can result in legal action
  • It is not necessary for the reporter to “prove” abuse has occurred, only reasonable concern or suspicion is required
  • Department of Children’s Services is available 24 hours a day by telephone (800) 540-4000











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