Child maltreatment

Child maltreatment is abuse or neglect of a person younger than 18. It usually involves a parent, caregiver, or another person in a position of responsibility, trust, or power. It can happen in any family or community.

Child maltreatment includes:

• Physical abuse, such as hitting, burning, shaking, or causing another physical injury
• Sexual abuse or exploitation, including sexual contact, exposing a child to sexual activity, or involving a child in sexual images
• Emotional or psychological abuse, such as repeated threats, humiliation, rejection, or intimidation
• Neglect, meaning a failure to meet a child's basic needs for safety, supervision, food, shelter, health care, education, or emotional support

A child may experience more than one type. Maltreatment can affect physical health, emotional well-being, development, learning, and relationships. Early recognition can help protect the child and connect the family with medical care and other support.

No single injury, behavior, or family circumstance proves maltreatment. Many possible signs can also have medical, developmental, or social explanations. Concerns should be assessed by professionals trained in child health and safety.

If a child is in immediate danger, has a serious injury, cannot be awakened, has trouble breathing, is bleeding heavily, or may have been poisoned, call local emergency services. If danger is not immediate but abuse or neglect is suspected, contact the appropriate child protection agency, law enforcement service, or child abuse reporting hotline where the child lives.

Children may not describe maltreatment directly. They may be afraid, feel responsible, want to protect someone, or lack the words to explain what happened. Some children show few outward signs.

Possible physical findings include injuries that are unexplained, repeated, or inconsistent with the child's developmental abilities. Examples include bruises, burns, fractures, head injuries, abdominal pain, genital injuries, sexually transmitted infections, poor growth, untreated medical problems, or consistently poor hygiene. An injury in a baby who is not yet moving independently may need especially careful assessment.

Behavioral and emotional changes may include:

• Sudden fear of a person, place, or going home
• Withdrawal, anxiety, sadness, aggression, or unusual irritability
• Sleep problems, nightmares, or bed-wetting after previous bladder control
• Falling school performance or frequent absences
• Sexual knowledge or behavior that is not expected for the child's age
• Running away, substance use, self-harm, or thoughts of suicide
• Strong hunger, taking food, or clothing that is repeatedly unsuitable for the weather

Neglect may be suspected when a child's health or safety needs remain unmet. However, poverty by itself is not neglect. Families may be unable to obtain food, housing, child care, transportation, or medical care despite trying to meet the child's needs. Assessment should identify both safety concerns and practical resources that could help.

If a child reports maltreatment, listen calmly. Let the child speak in their own words. Do not press for details, suggest answers, or repeatedly question them. Tell the child that it was right to speak up and that the situation is not their fault. Do not promise secrecy; explain that help may need to be requested to keep them safe.

Maltreatment is never the child's fault. A child's behavior, disability, health condition, or need for care does not cause abuse or neglect.

There is usually no single cause. Risk may be shaped by factors involving the caregiver, family, community, and wider society. These can include caregiver substance use, untreated mental illness, a history of violence, poor understanding of child development, social isolation, intimate partner violence, severe stress, and unstable housing or finances.

Children who are very young or who have disabilities, complex medical needs, or communication difficulties may be more dependent on caregivers and less able to report harm. This can increase vulnerability, but it does not mean maltreatment is occurring.

Community conditions also matter. Limited access to health care, mental health services, safe housing, affordable child care, and family support can raise stress and reduce opportunities for help. Protective factors include safe relationships, supportive relatives or friends, reliable health care, stable housing, positive parenting support, and schools or community programs that respond to concerns.

Risk factors help professionals understand where support may be needed. They cannot identify who has or has not harmed a child.

Child maltreatment is not diagnosed from one symptom or test. Evaluation focuses on the child's health, the explanation for any injury or concern, their developmental stage, and their current safety.

A clinician may speak separately with the child and caregiver when appropriate. Questions are usually open-ended and kept to what is needed for medical care. Detailed investigative interviews should be conducted by trained professionals to reduce repeated questioning and avoid influencing the child's account.

The physical examination depends on the concern. It may include a full skin examination, growth measurements, a neurologic assessment, and evaluation of the mouth, bones, abdomen, or genital and anal areas. A normal examination does not rule out abuse, particularly sexual abuse, because many forms of contact leave no injury or may have healed before the examination.

Testing is tailored to the child's age, symptoms, and history. It may include:

• X-rays or a skeletal survey to look for visible and hidden fractures
• Brain imaging when a head injury is possible
• Abdominal imaging or blood tests when internal injury is a concern
• Tests for bleeding, bone, or genetic conditions that might explain certain findings
• Pregnancy or sexually transmitted infection testing when medically appropriate

Clinicians document relevant statements and findings carefully. Photographs may be taken under clinical and legal procedures. A child abuse pediatrician, forensic examiner, or multidisciplinary child advocacy center may assist.

Health professionals in many locations are legally required to report reasonable suspicion of child maltreatment. They generally do not need proof before reporting. Reporting rules and the agencies responsible differ by location.

The first priorities are the child's immediate medical needs and safety. Serious injuries may require emergency treatment, surgery, hospital observation, or care from specialists. Less urgent injuries still need appropriate pain relief, wound care, and follow-up.

There is no medicine that treats maltreatment itself. Medicines may be used for specific injuries, infections, sleep problems, anxiety, depression, or other health conditions when a qualified clinician determines they are appropriate. After recent sexual exposure, clinicians may discuss time-sensitive testing, emergency contraception, vaccination, or treatment intended to prevent certain infections. These decisions depend on age, timing, exposure, examination findings, and local protocols.

Care should be trauma-informed. This means recognizing how frightening experiences can affect a child and avoiding unnecessary distress. The child should receive clear explanations, choices when possible, privacy, and support from a safe adult.

Mental health treatment may include trauma-focused therapy provided by a clinician experienced in working with children. Treatment can help with fear, guilt, sleep problems, behavior changes, depression, or traumatic stress. Safe caregivers may be included so they can support recovery.

Child protection services and law enforcement may assess safety. Depending on the circumstances, a plan may involve services in the home, supervision changes, temporary care by relatives or foster caregivers, or restrictions on contact with a suspected person. These decisions are made by the responsible agencies or courts, not by medical testing alone.

Support for non-offending caregivers can also be important. This may include counseling, parenting support, domestic violence services, substance-use treatment, food assistance, housing help, or respite care. Services should address practical family needs without losing focus on the child's safety.

A person who suspects maltreatment should not conduct their own investigation or confront a suspected abuser when doing so could increase danger. Record basic facts, including the child's exact words if a disclosure was made, and report the concern through local procedures.

Physical complications range from temporary pain to permanent disability. Head trauma, internal injuries, severe burns, poisoning, untreated illness, and some infections can be life-threatening. Sexual abuse may result in infection or pregnancy, although many affected children have no lasting physical injury.

Repeated or severe stress can affect a child's developing stress-response systems. Possible longer-term effects include anxiety, depression, post-traumatic stress symptoms, sleep disturbance, difficulty concentrating, behavior problems, self-harm, substance use, and challenges with trust or relationships.

Neglect can interfere with growth, language, learning, dental health, and management of chronic medical conditions. Frequent school absence or unstable living arrangements may further disrupt development.

These outcomes are not inevitable. Many children recover and function well, particularly when the harm stops, safety is restored, and they receive stable caregiving and effective treatment. Recovery may take time and may not follow a straight path.

Follow-up should address more than the original injury. The care team may monitor healing, growth, development, sleep, school functioning, emotional health, and the child's sense of safety. Repeat imaging or laboratory testing is sometimes needed, depending on the findings.

Children receiving mental health treatment may need ongoing visits to review symptoms and adjust the care plan. Caregivers should tell the clinician about new fears, nightmares, regression, aggression, withdrawal, self-harm, or major changes in school performance.

Routine follow-up may involve a primary care clinician, specialists, therapists, social workers, child protection professionals, and school staff. Sharing information should follow privacy rules and focus on the child's care and safety.

Seek urgent help if the child develops worsening pain, repeated vomiting, unusual sleepiness, confusion, weakness, breathing problems, new bleeding, or signs of a serious infection. Emergency assessment is also needed after a recent serious assault or if the child may be in immediate danger.

Statements about suicide, a suicide attempt, severe self-harm, or threats to harm someone else require immediate crisis or emergency support. Do not leave the child alone while arranging help.