Etiology
There is no specific etiologic factor of child abuse; causes and risk factors are multifactorial. The ways in which these factors interrelate to contribute to child maltreatment and the reasons why some caregivers, despite the presence of risk factors, are resilient and do not abuse children, are not well understood.
Parental (or caregiver) risk factors
Poor socioeconomic status (e.g., poverty, low income, and/or an economic crisis within the family). Other factors include inadequate child care and poor parental education.
The reported co-occurrence rate of domestic violence within the family, or an ongoing abusive relationship between partners in a violent intimate relationship, with child physical abuse ranges from 22% to 67%.[13]
Psychological problems such as depression, stress, or other mental health problems of a caregiver may expose the child to abuse.[6]
Substance abuse may inhibit the caregiver's ability to recognize the needs of the child, contributing to neglect, and may cause financial hardship. In addition, some children can end up in the role of "caregiver" for nonfunctioning adults, placing a huge burden on them.
Unmet emotional needs on the part of the parent or caregiver may predispose toward neglect of a child.
Lack of parenting knowledge may lead to unrealistic expectations of the child.
Parental or caregiver exposure to maltreatment as a child is a risk factor for child abuse, with evidence of a pattern of abuse running through generations in some families. This is thought to be due to sex-role stereotypes and a repetition of a pattern of violence.[14]
Child risk factors
Children with mental or physical health problems, particularly those with challenging behaviors, may be at a greater risk of abuse.[6][15] Children with disabilities have been noted to be twice as likely to be abused as nondisabled children, although maltreatment also contributes to disabilities.[16]
Low birthweight appears to be associated with a greater risk of abuse.[17]
Excessive crying and/or frequent tantrums have been associated with abusive head trauma (AHT).[18]
Twins and other multiples face an increased risk for abuse.[19]
Some research suggests that children of US military soldiers are approximately 3.5 times more likely to suffer from AHT than children of US civilian parents.[20]
Pathophysiology
The range of injuries caused by physical abuse include bruising, fractures, oral injuries, bites, head and spinal injuries, abdominal injuries, and burns. The pathophysiology depends on the individual type of injury.
Abusive head trauma (AHT) and related injuries can result from various biomechanical forces, including shaking alone, shaking with impact, or impact alone.[15][21] The presence of retinal hemorrhages in multiple retinal layers and extending to the periphery is highly specific for AHT, and it is seen in approximately 85% of cases.[22][23][24] Subdural hemorrhages are the most common intracranial injuries seen in AHT and may occur in combination with other extra-axial hemorrhages or injuries to the brain itself, such as subarachnoid hemorrhage and hypoxic ischemic injury (cytotoxic edema).[25][26][27]
The most specific abusive abdominal injuries are blunt force injuries to the hollow and/or solid organs in the absence of a clear history of trauma.[28]
Rib fractures in a child with no underlying bone disease or explicit history of major trauma have the highest specificity for abuse of any fractures. Such fractures are due to either the squeezing of the chest or a direct blow.[29] Fractures of long bones in premobile children and metaphyseal fractures are very common in abuse as well.[30][31] Any long bone fracture in a premobile child should have a clear accidental explanation, and if not, abuse should be actively excluded. Multiple fractures of differing ages and bilateral fractures are more common in abused than nonabused children.
Oral injuries, including a torn frenum (or frenulum), may be associated with severe or fatal abusive injury (usually head injury).[32][33][34] It is proposed that a torn frenum may occur by force-feeding of an infant, although it has only been conclusively reported following a direct blow.[34][35] Dental injuries include forced intrusions, extrusions, removal of healthy secondary teeth, and microfractures. None of these oral injuries are specific to abuse, and they must be evaluated keeping in mind the developmental age of the child and an appropriate explanation for the injury found.[36] Parents have been known to forcefully extract healthy teeth from their child as a "punishment."[37]
Classification
Classification by type of abuse
Physical abuse
May involve causing physical harm by hitting, shaking, burning, smothering, poisoning, biting, or throwing the child. Physical harm may also be caused when a parent or caregiver fabricates symptoms or deliberately induces illness.
Injuries sustained by physical abuse may include bruises, fractures, burns, oral injuries, bites, head and spinal injuries, and abdominal injuries.
The challenge for the clinician is to distinguish inflicted injuries from accidental injuries.
Emotional abuse
The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on emotional development. This may involve conveying to the child that they are worthless, unloved, inadequate, or valued only as long as they meet the needs of another person.[1][2]
May feature age- or developmentally inappropriate expectations being imposed on the child. These may include interactions that are beyond the developmental capability of the child, overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may also involve the child seeing or hearing the ill-treatment of another child or parent.
Includes serious bullying, causing a child to feel frightened or in danger, or the exploitation of the child.
Some level of emotional abuse is involved in all types of maltreatment of a child.[3]
Sexual abuse
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution and pornography, whether or not the child is aware of what is happening.
Activities may involve physical contact, including penetrative or nonpenetrative acts.
Actions may include noncontact activities, such as involving children in the viewing or production of sexual images or encouraging children to behave in sexually inappropriate ways.[3]
Neglect
Neglect is the failure to meet the basic physical and/or psychological needs of a child, likely to result in the serious impairment of health or development. It may also include neglect of, or unresponsiveness to, the basic emotional needs of a child.[2]
Neglect includes failure to:
Neglect may also occur during pregnancy as a result of the mother failing to consider the developing needs of the child.
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