Continuing Education Activity

Abuse and neglect refer to the actions or inactions of an individual's caregiver or parent inflicting physical, sexual, or emotional harm on the individual. Abuse and neglect may also be referred to as maltreatment and within the legal framework of a country or state is defined as constituting a criminal infringement of the rights of the maltreated individual. This activity outlines how abuse and neglect may present and means by which suspected abuse or neglect should be evaluated and managed. This activity reviews the importance of the interprofessional team in recognizing and treating abuse and neglect.

Objectives:

• Explain when abuse or neglect should be suspected and what evaluation should take place.
• Outline the process of reporting suspected abuse or neglect.
• Describe some of the factors that increase the risk of abuse and neglect.
• identify how communicating with team members to clarify reporting duties can lead to improved recognition and management of abuse and neglect and better patient outcomes.

Introduction

Abuse and neglect are commonly encountered in both children and the elderly. It occurs when a caregiver, whether through willful action or lack of appropriate action, causes harm or distress to the person under their care.[1][2] The victims can be encountered in different healthcare settings and may be at risk of various health consequences.[3][4] The optimal outcome for these individuals may depend upon early recognition of the signs and symptoms of abuse and/or neglect and prompt evaluation.  The following activity will provide an overview of the clinical features, evaluation, and approach to a patient with suspected abuse or neglect.

Etiology

Abuse and neglect of the child and the elderly are often perpetrated by the parent or caregiver responsible for their care. This can include physical abuse, sexual abuse or exploitation, psychological abuse, neglect or abandonment, and confinement.[5][6]

Predisposing factors for child abuse and neglect are multifactorial, ranging from socioeconomic stressors to harmful cultural practices all contributing to the various degree of vulnerability among the world child population.[7][8] Some of the identified risks are as follows:

• Poor socioeconomic status: Poverty and unemployment among parents provide an unfortunate premise for abuse. Neglect may be a result of a parent not able to provide basic needs for the child.
• Domestic violence: Parents who abuse their partners have an increased tendency to abuse their children either directly or by indirect emotional trauma from the child constantly witnessing domestic violence.
• Drug and alcohol abuse: Parents who abuse drugs or alcohol are likely to be abusive.
• Unwanted or unplanned pregnancy: Product of unwanted or unplanned pregnancy may suffer abuse or neglect either because the unprepared mother, who also may be a child, is not emotionally ready for the role.
• Gender-based discrimination: In some societies, the female child is even more at risk. They suffer gender-based violence like female genital mutilation, early child marriage, and denial of education.

The following factors predispose the elderly to abuse and neglect:

• Caregiver burnout: Care of the elderly can be burdensome.
• Chronic health challenges: Elderly patients are over-dependent, and the caregiver may not be prepared to provide the needed support.
• The onset of mental and behavioral challenges: The onset of memory loss in diseases like dementia and Alzheimer's disease makes the elderly prone to abuse and neglect.

Epidemiology

The prevalence of child abuse and neglect varies widely. Available estimates suggest that as much as a quarter of the world adult population may have experienced some form of abuse or neglect during childhood with a slightly higher incidence in female subjects.[9]

These values may not truly represent the actual incidence due to under-reporting.[10]

Children are also victims of war and violent crimes. The World Health Organization (WHO) in 2014 estimated about 41,000 cases of child homicide occur yearly.[11]

Abuse of the elderly is equally common. In the United States of America, 1 in 10 people older than the age of 60 may have experienced some form of abuse, amounting to about 5 million cases per year.[12]

History and Physical

Child Abuse and Neglect

History

Depending on the age of the child, historical information is often primarily obtained from the caregiver and the comments provided by the patient (especially in older children and adolescents). Children who suffer from abuse or neglect may present with typical presenting complaints (i.e. vomiting). Therefore, for the clinician who sees pediatric patients regularly, it is important to keep child abuse or neglect in the differential diagnosis during every visit to enhance the likelihood of recognition. 

The approach to history taking should be structured, systematic, with the flexibility to allow different lines of questions, and thus similar to how a clinician obtains a routine history. This will not only ensure rapport with the patient and the caregiver, but it enhances the ability of the clinician to quickly investigate any historical and physical features that are concerning for child abuse or neglect.[13]

There are various historical features that should raise the suspicion for abuse.[14] 

These include: 

1. Lack of history of trauma in a pediatric patient with severe injuries[15]

2. History describing the mechanism of injury inconsistent with the child's developmental level[13]

3. Unexplained delay in seeking care before presenting to a medical provider[16]

4. History describing injuries attributed to household pets or other young children[17]

5. The initial history is vague or changes amongst different caregiver accounts[18] 

6. Significant changes in personality and/or sleeping/eating habits[19][20]

Physical Examination

The physical examination should be routine, systematic, and focus on findings that may indicate an underlying etiology of the child's initial complaint, including the possibility of child abuse or neglect. This begins with the general appearance of the patient and how they interact with their caregiver. This may include but is not limited to lack of interaction between the patient and the caregiver (i.e. patient not seeking comfort or caregiver not offering comfort), not appreciating the severity of the patient's condition, assigning blame to the child for their injuries or illness, treating the patient differently than the other children in the room, and if the patient displays fear towards the caregiver present.[21][22]

There are various presenting features that should raise the suspicion for abuse. These include: 

Physical abuse

1. Bruises in infants less than 6 months (infants not yet freely mobile), bruises situated away from bony prominences, and bruises with a unique shape (like the shape of an object) are highly suggestive of abuse[23][24]

2. Human bite marks[17]

3. Oral injuries (including frenulum tears, lip lacerations, tongue lacerations, fractures; especially in infants)[25]

3. Limping (an indication of the possibility of a fracture)[23][24]

4. Unexplained hair loss[23][24]

5. Retinal hemorrhages[23][24]

6. Unexplained loss of a tooth[23][24]

7. Unexplained bruising on the abdomen[23][24]

8. Altered consciousness (possibly indicating head injury)[23][24]

9. Intentional burns (scalds from hot tap water, burns that resemble the shape of burning objects, cigarette burns)[17]

Sexual abuse

1. Nonspecific symptoms (abdominal pain, fecal incontinence, constipation)[26]

2. Genital bruising and/or bleeding[26]

4. Behavioral or personality changes[26]

5. Inappropriate behavior especially of the sexual nature (for example, an unusual interest in genitals of other children or even adults)[26]

Emotional abuse and neglect 

1. Poor hygiene[27]

2. Signs of malnutrition (child may refuse meals)[27]

3. Child may appear withdrawn with inadequate social interaction[27]

4. Developmental milestone delays (such as speech and motor delays)[28]

Adult Abuse and Neglect

History

Depending on the patient's underlying health condition, historical information may be obtained from the caregiver and the comments provided by the patient. If possible, it is best to solicit the history from the patient and the caregiver separately.

The approach to history taking should be structured, systematic, with the flexibility to allow different lines of questions, and thus similar to how a clinician routinely obtains a history. This will not only ensure rapport with the patient and the caregiver, but it enhances the ability of the clinician to quickly investigate any historical and physical features that are concerning for elder abuse or neglect.[29]

There are various historical features that should raise the suspicion for abuse. These include:

1. Mechanism of injury that is implausible based on the patient's condition[30]

2. History is inconsistent, vague or different between the patient and caregiver[29]

3. Delay in seeking medical attention[31]

4. Past history of frequent injuries or unexplained visits to the emergency department[31]

5. Caregiver unable to give details regarding the patient's medical history or the medications they are taking[31][32][31]

6. Caregiver answers questions for the patient[31]

7. The patient is reluctant to answer questions[33]

Physical Examination

The physical examination should be routine, systematic, and focus on findings that may indicate an underlying etiology of the patient's reason for the visit. This begins with the general appearance of the patient and how they interact with their caregiver. The clinician should observe the patient for any signs of fear, anxiety, infantile behavior, poor self-esteem, and/or mistrust in the presence of the caregiver. Caregivers may be emotionally abusive. 

There are various physical features that should raise the suspicion for abuse. These include: 

1. Unexplained signs of injury: Bruises, burns, scald, fracture, signs of restraints on the hands and feet[30]

2. Bedsores (pressure ulcers)[30]

3. Poor hygiene[30]

4. Signs and symptoms of dehydration, malnutrition, or unexplainable weight loss[34]

5. Emotionally withdrawn and showing signs of depression[31]

6. Refusal to take routine medications or drug overdose[35]

7. Hair loss[30]

8. Broken teeth[30]

9. Lacerations[34]

10. Evidence of trauma on a genitourinary exam or vaginal bleeding[34]

Evaluation

When abuse or neglect is suspected in a patient of any age, the clinician should order testing as indicated by the history and physical examination. These may include:

Imaging Studies 

1. Computed tomography of the brain to rule out any intracranial hemorrhages[13][36]

2. Chest radiographs to rule out thoracic injuries and/or the presence of any acute fractures or fractures in various different stages of healing[13][36]

3. Global skeletal surveys in children that images subtle metaphyseal, rib, and other injuries specific for abuse[37]

4. Computed tomography of the abdomen to rule out the presence of any intraabdominal injuries particularly duodenal or pancreatic injuries, but also liver, spleen, kidney, adrenal gland, mesentery, and/or intestinal injuries[13]

5. Ophthalmologic evaluation to rule out the presence of retinal hemorrhages[13]

Laboratory Testing 

1. Basic Metabolic Panel to evaluate for any electrolyte or nutritional abnormalities[38][39]

2. Toxicology Testing to rule out the presence of malicious administration of substances[40]

3. Coagulation Profile to rule out the presence of bleeding disorders[41][13] 

4. Serum Lipase to rule out pancreatic injury[13]

5. Hepatic Function Panel to rule out the presence of intraabdominal injury[13]

6. 25-hydroxy vitamin D level, intact parathyroid hormone level, calcium level[41][13]

7. Creatinine kinase level to rule out the presence of rhabdomyolysis[42][39]

8. Urinalysis to rule out the presence of myoglobinuria[42][39]

9. Urine organic acids to rule out the presence of metabolic conditions such as glutaric acid type I[13]

Treatment / Management

A high index of suspicion is required to make a diagnosis of non-accidental injury or abuse and neglect. While promptly attending to physical injuries, it is important to note that abuse and neglect have more lingering emotional or psychological sequelae that require management. The care of abused and neglected individuals and therefore requires a multidisciplinary approach. In managing child abuse and neglect, the following specialists must work together: general practitioners, emergency room doctors, pediatricians, psychiatrists, child psychologists, social workers, law enforcement officers, and members of the child protective services. Elder abuse and neglect require the services of general practitioners, emergency room doctors, geriatric specialists, psychiatrists, social workers, law enforcement officers, and members of adult protective services.[43][41]

Management of abuse and neglect involves:

• Treating presenting injuries and complaints
• Reporting to appropriate authorities
• Involving services of psychiatrists and psychologists
• Discharge to child or adult protective services
• Long-term follow-up and rehabilitation

Differential Diagnosis

Child Abuse

There are various conditions where the clinical manifestations may be mistaken for child abuse. The clinician must be familiar with these diseases as some may require prompt initiation of appropriate therapy for the actual underlying condition and to avoid unnecessary evaluation for child abuse.

This is summarized below by the clinical findings: 

1. Bruising 

1. Bleeding disorders (i.e. Hemophilia A, von Willebrand disease, Vitamin K deficiency, immune thrombocytopenia)[44]
2. Exploratory ingestion of medications (i.e. Salicylates)[45]
3. Vasculitides (i.e. Henoch-Schonlein purpura)[46]
4. Congenital birthmarks (i.e. Dermal Melanosis/Mongolian spots)[47]
5. Benign Tumors (i.e. hemangiomas)[48]
6. Delayed subaponeurotic fluid mass[49]
7. Hypersensitivity syndromes (i.e. erythema multiforme)[50]
8. Cultural practices to improve circulation and relieve common symptoms (such as coining, spooning, cupping)[51]

2. Fractures 

1. Osteogenesis imperfecta[52]
2. Osteopenia[52]
3. Metabolic bone disease (i.e. Rickets, Vitamin C and Copper deficiency, or oncological disorders)[52]
4. Ehlers-Danlos syndrome[53]
5. Injury during resuscitation (i.e. rib fractures, internal organ contusions, retinal hemorrhages)[54]

3. Burns

1. Chemical and irritants (i.e. bleach, complementary and alternative therapies)[55]
2. Infection (i.e. impetigo, blistering distal dactylitis, ringworm)[56][57]
3. Stephen-Johnson Syndrome[58]
4. Toxic epidermal necrolysis[58]
5. Dermatological conditions (i.e. diaper dermatitis)[57]

4. Intracranial Hemorrhage

1. Trauma not secondary to abuse (i.e. vacuum extraction during delivery)[59]
2. Inborn errors of metabolism (i.e. glutaric aciduria type I)[60]
3. Neoplastic diseases (i.e. brain tumor)[61]
4. Congenital vascular conditions (i.e. arteriovenous malformation, aneurysms)[62]
5. Bleeding disorders[44]
6. Collagen vascular disease (i.e. Ehlers-Danlos syndrome)[53]

Elder Abuse 

For elder abuse and neglect the following conditions should be considered:

1. Anorexia

1. Depression or other psychiatric conditions[63]
2. Dementia[63]
3. Delirium[63]
4. Adverse effects of prescribed, over-the-counter, herbal medications[63]
5. Cerebral vascular accidents (multiple resulting in increasing difficulty or dependency in completing activities of daily living)[63]
6. Use of alcohol or illicit drugs[63]
7. Dysphagia[63]
8. Dental problems[63]
9. Acute and Chronic Infection (i.e. urinary tract infection, sepsis, tuberculosis, endocarditis)[63] 
10. Endocrinologic diseases (i.e. hyperthyroidism)[63]

2. Fractures

1. Malignancy (resulting in pathologic fractures)[64]
2. Osteopenia (resulting in pathologic fractures)[64]

Prognosis

Child and elder abuse and neglect are associated with increased morbidity and mortality. [3][4][27][65][4] If recognized early, clinicians may potentially be able to impact the medical and psychological consequences. 

Complications

Elder abuse and neglect are associated with increased morbidity (particularly the development of depression, dementia, cognitive impairment, loss of functional capacity) and increased mortality.[4][65][4] Child abuse and neglect are associated with lifelong medical, psychological, and social consequences as well as increased risk of future abuse.[3][66] 

Deterrence and Patient Education

Parents and caregivers of children and the elderly should be counseled on the common signs and symptoms indicative of child and elder abuse and neglect.

For the child, parents and caregivers should be counseled to observe for unexplained bruises or markings, oral injuries, change in behavior (i.e. withdrawn in a young child, excessive crying in an infant), genitourinary abnormalities, behavioral change, inappropriate behavior (especially of a sexual nature).[14]  

For the elderly, the caregiver or family member should observe for unexplained injuries (including bruises, burns, fractures), pressure sores, change in behavior, weight loss, lack of food, dehydration, urinary or fecal incontinence, genitourinary injury, and poor hygiene.[4] 

If a caregiver is having difficulty providing care, they should be advised to notify a physician or nurse. The physician or nurse can counsel the caregiver, especially if they are the primary caregiver of the child or elderly person, in how they can obtain support or help so that they are not overwhelmed.[67] 

Pearls and Other Issues

Different countries have legislation and policies for abuse and neglect against children or the elderly. The healthcare provider is mandated by law to report non-accidental injuries and suspected cases of abuse and neglect. The failure to report abuse may qualify legally as a misdemeanor.

Enhancing Healthcare Team Outcomes

Child abuse and neglect is a major public health problem. Even though there is more awareness of this social problem among healthcare workers, the problem still exists. Every day, at least 700 children are removed from their homes because of abuse and neglect. For many, the scars of physical, sexual, and mental abuse linger throughout life. Countering child abuse and neglect is not only the responsibility of the physician but all healthcare workers. There are laws in every state which encourage all healthcare workers to report child abuse, without fear of any repercussions.[68][69]

The diagnosis of child abuse is not simple and requires a high degree of suspicion on the part of healthcare workers who encounter the child and the family. Abused children not only present to the physician but may have encounters with nurses, pharmacists, therapists, lab technologists, and many other allied professionals and all these professionals have a legal and moral duty to report any suspicion of child abuse. Those who do not report child abuse can even incur legal penalties. When child abuse goes undetected, it carries enormous morbidity and mortality for the child. Abused children often have unhealthy development with emotional scars that remain for life.[70][71]

Child advocacy centers recommend an interprofessional team approach for child abuse detection. In many circumstances, a child may remain silent in the presence of a clinician but may reveal the dark secrets of abuse to other professionals. Thus, nurses, pharmacists, and other allied healthcare professionals must be vigilant about child abuse. Many screening tools have been developed, which can help healthcare workers make the diagnosis of child neglect or abuse. When a nurse or other health professional determines abuse is a concern, they should report to the clinical team leader their findings. Only through teamwork will better outcomes be achieved.[72]

Despite better awareness of the problem of child abuse, healthcare workers still miss many cases of abuse and neglect.[73][74] The key reason is that some healthcare workers falsely believe that it is physicians who are solely responsible for intervention, which is erroneous thinking. All healthcare workers should report any suspicious case of child abuse and can verify with other members of the healthcare team to corroborate their findings. If done in good faith, the law will always protect them. This discernment and interaction/communication is a key component of a properly functioning interprofessional team and can be lifesaving as much as any other therapeutic activity.[Level V]

Elder abuse and neglect is also a major public health concern. Clinicians must have a high index of suspicion and distinguish the clinical features of aging from elder abuse and neglect. In patients with risk factors, this may require the creation and use of screening questions (by all professionals), prompting further evaluation, and referral to the appropriate adult protective agency.[75][76][75][Level V]  

Multidisciplinary medical response teams dedicated to elder abuse and neglect may be utilized to help evaluate suspected patients of abuse or neglect and confirming the presence of abuse. [77][78][Level 5]