Child abuse

Disease Description (Causes and Symptoms)

• Definition: Any act by a guardian (or adult) that impairs a child’s physical, psychological, or sexual safety or normal development (including physical abuse, emotional abuse, sexual abuse, neglect, and abandonment).
• Causes and risk factors
  • Parent factors: Personal experience of abuse during childhood, alcohol or drug problems, inability to regulate emotions, mental illness (such as depression or anxiety), abnormal sexual desires, etc.
  • Child factors: Prematurity, congenital abnormalities, disabilities, developmental delay, high care demands (frequent crying, sleep problems), and problematic behavior may increase the burden of caregiving and become risk factors (whether they are causes or consequences varies by case).
  • Family and social factors: Structural problems such as single-parent families, families with underage members, and remarried families; social isolation; cultures that tolerate corporal punishment; lack of support from those around the family, etc.
• Pathophysiology (Effects)
  • Physical injuries: Bruises, fractures, burns, spinal cord and brain injuries (including shaken baby syndrome, etc.).
  • Changes in neurodevelopment and stress responses: HPA axis dysfunction due to chronic stress, delayed emotional, cognitive, and social development, attachment disorders, and possible development of PTSD.
• Main symptoms (Physical and behavioral)
  • Physical signs: Unexplained injuries, burns, or fractures; a history of repeated trauma; failure to receive treatment, etc.
  • Emotional and behavioral signs: Withdrawal or excessive aggression, fear of others, school avoidance, stealing, bed-wetting, regression, sleep disorders, sudden personality changes, self-harm or suicide attempts, etc.
  • Signs suggesting sexual abuse: Abnormal sexual knowledge or sexual behavior, genital injuries, sexually transmitted infections, pregnancy, etc.

Treatment Methods and Precautions

• General principles
  • Ensure safety first: Check whether the child is in immediate danger (in emergencies, provide first aid and contact a child protection agency or the police). Medical professionals have a legal duty to report (according to national and regional regulations).
  • Multidisciplinary approach: Coordinate with pediatrics, emergency medicine, psychiatry (child and adolescent psychiatry), dermatology, surgery, obstetrics and gynecology (when sexual abuse is suspected), social welfare and child protection agencies, and forensic medicine.
• Medical treatment
  • Trauma treatment: Wound care, fracture immobilization and surgery, burn treatment, and evaluation of neurological injuries (brain imaging and neurosurgical assessment).
  • Related to sexual abuse: Physical examination and forensic evidence collection, testing for sexually transmitted infections (chlamydia, gonorrhea, HIV, HBV, etc.), emergency contraception and, when necessary, HIV PEP (depending on the time since exposure and the level of risk), and consideration of vaccination (for example, hepatitis B and HPV).
  • Mental health treatment: Trauma-focused treatment (for example, TF-CBT: Trauma-Focused CBT), parent-child interaction therapy (PCIT), and medication used only for accompanying psychiatric symptoms (depression, anxiety, ADHD, etc.) based on a specialist’s judgment.
• Social and legal intervention
  • Referral to child protection agencies and social welfare services, consideration of a protective setting (temporary protection or foster care), and support for legal procedures (such as investigations and preparation for court testimony).
• Lifestyle management and family therapy
  • Parent education, stress and addiction treatment, development of a safety plan at home, and connection with community resources.
• Precautions and complications
  • Do not delay when preserving evidence (examinations and photographs may be necessary); during investigations, take care not to make the child repeatedly recount the events.
  • Long-term complications: Chronic mental health problems (depression, anxiety, PTSD, and substance use disorder), developmental delay, interpersonal and academic problems, and increased risk of self-harm and criminal behavior.
  • Medical professionals should approach the situation objectively and without bias, prioritizing the child’s safety above all else.

Checklist Before an Outpatient Visit (Including Recommended Items, Records, and Example Questions)

• Items to bring (recommended)
  • A list of currently used medications (prescription and nonprescription) and allergy records.
  • Copies of previous medical records and test results (imaging, medical certificates, etc.).
  • The time and circumstances when injuries or symptoms occurred (a timeline by time period), and photographs of injuries (if possible, indicate the date they were taken).
  • School attendance records and observations from teachers or childcare providers (if available).
  • Information and contact details for the guardian and family members, and the caregiving situation (including whether another adult is involved).
• Information to confirm during the outpatient visit (information to tell the medical professional in advance)
  • The exact time and description of any recent trauma or symptoms (including who was present at the time).
  • Whether similar incidents occurred previously and whether treatment was received.
  • When changes in the child’s behavior, sleep, appetite, or school life began and their characteristics.
  • The child’s safety (whether the current threat is continuing) and whether separation from the guardian is possible.
• Interview guidance
  • Interviews with the child should be conducted in an age-appropriate, trauma-informed manner. If evidence collection is necessary, medical professionals should explain the procedure before carrying it out.
  • If possible, arrange interpretation and psychological counseling personnel.

Examples of General Questions to Ask the Doctor

• How serious is this child’s current physical risk? Is immediate protection necessary?
• What tests are needed for diagnosis (imaging, blood tests, sexually transmitted infection tests, etc.)?
• What is the treatment plan for the injuries or fractures? Will surgery or hospitalization be necessary?
• What type of mental health treatment is recommended? If medication is necessary, what are its side effects?
• How will the reporting and protection procedures proceed, and what information will be provided to the parents or guardian?
• How will the schedule for future follow-up and connections to educational and social welfare resources be arranged?

Examples of Condition-Specific Questions

• If physical abuse is suspected
  • Considering the form of this injury (or fracture) and the time it took to heal, how likely is an accidental cause?
  • What past trauma history or examinations of other parts of the body should be checked in addition?
• If sexual abuse is suspected
  • If the exposure occurred several hours or days ago, which emergency treatments and tests should be prioritized (emergency contraception, sexually transmitted infection tests, DNA testing, etc.)?
  • Where and through what procedures will the forensic examination (evidence collection) be conducted, and how will the results be preserved?

(When necessary, medical professionals may adjust the priority of examinations and treatment according to the child’s age, symptoms, and time since exposure. If an immediate danger is suspected, contact the emergency room, a child protection agency, the police, or other relevant organizations immediately.)