Definition from the Federal Child Abuse Prevention and Treatment Act (CAPTA): Any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse or exploitation of a child; or an act or failure to act that presents an imminent risk of serious harm to a child.¹ More specific definitions may be found in individual state criminal and Child Protective Services statutes, but the general definitions are as follows.

• •Neglect: Failure to provide for the basic needs of a child
  1. 1.Physical neglect: Failure to provide necessary food, shelter, and supervision
  2. 2.Medical neglect: Failure to provide necessary medical, dental, or mental health care
  3. 3.Educational neglect: Failure to meet a child’s educational needs
  4. 4.Emotional neglect: Failure to attend to emotional needs, exposure to domestic violence
  5. 5.Abandonment: Child left and parents’ whereabouts unknown or parents refuse to care for child
  6. 6.Parental substance abuse: Includes prenatal exposure to mother’s use of illicit drugs, manufacture of drugs (e.g., methamphetamine) in the presence of a child, selling or giving drugs to a child, use of mood-altering substance by caregivers that impairs their ability to provide care for a child
• •Abuse: Act that causes harm or significant risk of harm to a child
  1. 1.Physical abuse: Physical injury or significant risk of injury inflicted by a parent or caregiver intentionally, including in the course of excessive discipline
  2. 2.Sexual abuse: When an adult or adolescent engages a child or nonconsenting adolescent in sexual acts, including sexual exploitation, trafficking, and child pornography. Sexual abuse can involve both contact or noncontact activities
  3. 3.Emotional/psychological abuse: Pattern of behavior of caretaker toward a child that impairs emotional development. This includes verbal abuse, cruelty, and threats
  4. 4.Medical child abuse: Unnecessary, excessive, and potentially harmful medical care obtained at the instigation of a caregiver through exaggeration, falsification, or inducement of symptoms

• Child maltreatment syndrome
• Physical abuse
• Sexual abuse
• Battered child syndrome
• Shaken baby syndrome
• Shaken impact syndrome
• Abusive head trauma
• Neglect

The differential diagnosis should include possible medical causes, accidental causes, and abuse. Conditions that can mimic child abuse are summarized in Table E3.

History and physical examination:

• •Careful history should be obtained and documented from all caregivers, separately if possible.
• •Careful history should be obtained from the child. When children are less than 14 yr of age, history should be obtained in a forensically informed manner without asking direct or leading questions. A referral to a Children’s Advocacy Center may be indicated.
• •Scene investigation may be necessary and is typically conducted by law enforcement and/or CPS.
• •Complete head-to-toe physical examination.
• •Sexual abuse: Forensic interview and well-documented, photographed examinations by trained professionals are the standard for evaluation and evidence collection. This is especially important to avoid further psychological or physical trauma to the child.

Figure E4 Management of suspected child abuse.

ALT, Alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CBC, complete blood count; ESR, erythrocyte sedimentation rate; INR, international normalized ratio; PTT, partial thromboplastin time; TSH, thyroid-stimulating hormone; U/A, urinalysis.

Laboratory tests to assess for bleeding disorder in the case of children with suspicious bruising. These tests may not be necessary if the abuse was witnessed or if the child has clear patterned bruising or other indicators of physical abuse⁸:

• •CBC with differential and platelets
• •Prothrombin time, activated partial thromboplastin time
• •Von Willebrand factor antigen and activity
• •Factor VIII and IX levels
• •Alanine aminotransferase, aspartate aminotransferase, amylase, lipase, urinalysis should be considered in infants or other children with abdominal bruising or concern for occult abdominal trauma to look for evidence of internal injury to the liver, pancreas, or kidneys

Laboratory tests to assess for bleeding disorder in the case of children with suspicious intracranial hemorrhage (i.e., Abusive Head Trauma)⁸:

• •CBC with differential and platelets
• •Prothrombin time, activated partial thromboplastin time
• •Factor VIII and IX levels
• •D-dimer and fibrinogen if there is neurologic compromise
• •Consultation with a child abuse expert physician should be strongly considered in children with suspicion of abusive head trauma

Laboratory tests for sexual abuse:

• •If within 72 h of acute sexual assault/abuse, a forensic evidence kit (rape kit) can be collected. Swabs are obtained from the oropharynx, areas of skin exposure (use an alternate light source or history provided to identify appropriate areas), genitalia, and rectum to send to the crime lab for DNA and other testing. Also collect samples of foreign hair, blood, saliva, or other tissue if present. Underwear and clothing can also be collected. Referral to a local emergency department is often required.⁷
• •Per current CDC recommendations, adolescent victims of acute assault should have appropriate specimens collected from sites of penetration or attempted penetration for Neisseria gonorrhoeae and Chlamydia. Nucleic acid amplification tests (NAATs) may be used and are preferred. NAATs are also available for trichomonas testing. If there is itching, vaginal discharge, or malodor present, wet mount for bacterial vaginosis and Candida should also be done. Serum should be obtained for HIV, hepatitis B, and syphilis testing acutely. If negative, HIV and syphilis testing should be repeated 6, 12, and 24 wk after the assault.^7,9
• •Children (i.e., prepubertal) who have been sexually abused should receive testing for sexually transmitted infections (STI) if clinically indicated. Testing for gonorrhea and chlamydia is typically obtained via NAAT testing due to it being less invasive and more sensitive than culture. NAAT testing is most easily obtained from a urine sample but can also be obtained from a vaginal swab by an experienced examiner if discharge is present. If there is concern for oral or anal sexual contact, NAAT testing can be obtained from those sites. Due to the medicolegal implications of positive STI testing in prepubertal children, confirming the positive test result via NAAT testing of a second nucleic acid sequence is recommended. Testing for other sexually transmitted infections including T. vaginalis, HIV, syphilis, and hepatitis can also be obtained in prepubertal children when there is concern for sexual abuse.⁷

Physical abuse:

• •Radiographic skeletal survey for all children with suspicious injuries up to 2 yr of age. Additionally, a skeletal survey should be considered for any sibling or household member less than 2 yr of age of a child who has been physically abused. Skeletal surveys can be done on older children when there are extenuating circumstances (severe battering, homicide). In many cases, a repeat skeletal survey should be done 2 to 3 wk after the initial skeletal survey. Adjunct imaging (MRI, ultrasound, bone scan) may be useful to further define suspicious lesions seen on plain films. Skeletal survey should conform to American College of Radiology Standards.³
• •Noncontrast head computed tomography (CT) scan or MRI for all children <6 mo of age with concern of physical abuse. Head imaging should be considered for children 6 mo to 1 yr with concern of physical abuse. Children over 1 yr of age should have head imaging if neurologic changes or per clinical judgment.³
• •When injury or possible injury is identified on head CT, a brain MRI should be obtained.
• •Abdominal CT scan if indicated by clinical examination or laboratory evaluation suggest abdominal trauma.³
• •Box E1 describes the specificity of radiologic findings for child abuse.

• •Stabilize and treat acute medical injuries.
• •Report to CPS. HIPAA allows reports for suspected child abuse without parental authorization.
• •Report to law enforcement for suspected physical abuse or sexual abuse.
• •Early report to CPS and/or law enforcement may allow for scene investigation.
• •A safe disposition plan should be determined prior to any hospital discharge. This may involve coordination with the multidisciplinary team (physicians, law enforcement, family, and CPS). Disposition, once medically stable, is dependent on CPS. The child cannot be returned home if the environment is not safe.
• •Physicians should remain available to discuss with investigators. This is often critical to determining the outcome of the case and placement of the child.
• •Because follow-up of adolescent sexual assault victims can be difficult to coordinate, many experts recommend offering empiric treatment for STIs: Gonorrhea, Chlamydia, Trichomonas, and bacterial vaginosis. Emergency contraceptives should also be offered. A triage protocol for children with suspected sexual abuse is illustrated in Fig. E5. Hepatitis B immunization should be offered if not previously given. HIV postexposure prophylaxis is offered in certain situations depending on local epidemiology and type of assault. Indications for STI screening in children with suspected sexual abuse are described in Table E4. Consult local infectious disease experts for current recommendations. Repeat evaluation should be done in 2 wk for all victims of sexual assault, especially if they declined empiric treatment. If empiric treatment was not completed, STI and pregnancy testing should be repeated at the 2-wk follow-up visit.⁷
• •Empiric treatment of prepubescent children who have been sexually abused is generally not recommended. This is especially important if NAATs are used for screening for STIs because confirmation is necessary for any positive results. Careful follow-up within 2 wk and treatment based on culture results are indicated. HIV postexposure prophylaxis is offered in certain circumstances according to local epidemiology and risk. Consult with a local infectious disease expert for further recommendations.⁷

Figure E5 Triage protocol for children with suspected sexual abuse.

(From Kliegman RM et al: Nelson textbook of pediatrics, ed 22, Philadelphia, 2025, Elsevier.)

• •Often depends on CPS and court-ordered interventions
• •Treatment of parental mental illness
• •Treatment of parental substance abuse, including requirements for random drug testing
• •Instruction for parents in behavior management skills, including appropriate limit setting and discipline
• •Anger management classes for parents
• •Trauma-focused cognitive-behavioral therapy is an evidence-based practice for victims of sexual abuse and exposure to domestic violence; useful to include nonoffending parent/caregiver¹⁰
• •Ongoing individual and family therapy¹¹:
  1. 1.Parent-child interactive therapy is an evidence-based practice that is used with young children with behavioral problems and parent-child relationship problems.
  2. 2.Child-parent psychotherapy is an evidence-based practice that is for young children (<5 yr) who have experienced a trauma and their caregivers.
• •May need long-term placement in foster care before it is safe to return home. In extreme cases of abuse, parental rights may be terminated

• •Victims of chronic abuse and neglect:
  1. 1.Have higher rates of mental illness (depression, suicide, posttraumatic stress disorder, eating disorders)
  2. 2.Have more cognitive difficulties, often impaired academic performance
  3. 3.Are more likely to become aggressive and have challenging behaviors
  4. 4.Are more likely as adults to have adverse physical health outcomes (cardiovascular disease, cancer, STDs)
• •Victims of abusive head trauma:
  1. 1.One third die, one third have severe disability, one third have no identified morbidities in the short term

• •Home visitation by a specially trained nurse to high-risk families during pregnancy and infancy has shown positive outcomes as a prevention approach (Nurse-Family Partnership)
• •Anticipatory guidance at health visits to teach normal developmental expectations and appropriate discipline
• •Screening to identify at-risk or abused children
• •Targeted education in the newborn nursery for prevention of abusive head trauma has been shown to be partially effective
• •Substance abuse prevention and treatment
• •Identification and intervention for intimate partner violence
• •Public health recommendations to reduce the effects of media violence on children and adolescents are described in Box E2.

• Protecting Children From Abuse (Patient Information)