Child Abuse: Warning Signs and How to Get Help

Types of child abuse

Neglect

The most commonly reported form. It means failing to meet a child's basic needs:

• food, clothing, shelter and hygiene
• supervision appropriate to age
• medical and dental care
• education
• emotional care and attention

Signs include constant hunger, poor weight gain (failure to thrive), dirty or inappropriate clothing, untreated medical problems, frequent absence from school and being left alone for long periods.

Physical abuse

Non-accidental injury such as hitting, shaking, kicking, burning, biting or throwing a child. Warning signs:

• bruises in unusual places: the ears, neck, torso, buttocks, genitals or face (the "TEN-4-FACESp" areas), in any child under 4
• any bruise in a baby who is not yet cruising ("those who don't cruise rarely bruise")
• patterned injuries: handprints, loop marks from cords, belt buckles, bite marks
• burns: cigarette burns, or immersion burns with sharp edges on the hands, feet or buttocks
• fractures in infants, multiple fractures at different stages of healing, rib fractures
• injuries without a plausible explanation, or with a story that changes

Abusive head trauma (shaken baby syndrome) is the leading cause of death from physical abuse in children under 2. Babies may be irritable, vomit, feed poorly, become drowsy, have seizures or stop breathing, sometimes with no visible bruises. Persistent crying is a common trigger.

Sexual abuse

Any sexual activity with a child, including touching, exposure, exploitation and online abuse. Children often do not tell, or tell gradually. Possible signs:

• sexual knowledge or behavior inappropriate for age
• genital pain, bleeding, discharge, or sexually transmitted infections
• pregnancy in a young teen
• fear of a particular person or place
• new bedwetting, nightmares or regression

Emotional abuse

Persistent rejection, humiliation, threats, terrorizing, isolation, or exposing a child to domestic violence. Signs include low self-esteem, anxiety, withdrawal, aggression and delayed development.

Behavioral signs at any age

• sudden changes in behavior, mood or school performance
• fearfulness, being overly watchful, or seeming afraid to go home
• withdrawal, depression, anxiety or aggression
• running away, substance use or self-harm in older children
• reluctance to change clothes in front of others

None of these alone proves abuse, but patterns and combinations should be taken seriously.

Risk factors

Abuse occurs in every community and income level. Risk is higher when caregivers face:

• high stress, poverty, unemployment or housing instability
• substance misuse or untreated mental illness
• domestic violence in the home
• social isolation and lack of support
• their own history of abuse
• unrealistic expectations of a child's behavior

Children with disabilities, chronic illness and very young children are more vulnerable.

How doctors evaluate suspected abuse

Pediatricians and child abuse specialists:

• take a careful history from caregivers and, when appropriate, the child
• examine the whole body, including the skin, mouth, ears and genitals
• document injuries with photographs
• may order a skeletal survey (X-rays of all bones) in children under 2, head CT or MRI, eye examination for retinal bleeding, blood tests to rule out bleeding disorders, and tests for sexually transmitted infections
• report to child protective services, as required by law

Doctors also consider medical conditions that can mimic abuse, such as bleeding disorders, osteogenesis imperfecta and birthmarks like congenital dermal melanocytosis.

How to report and get help

• Immediate danger: call 911.
• Child protective services (CPS): each state has a reporting line; anyone can report, and you do not need proof, only a reasonable suspicion.
• Childhelp National Child Abuse Hotline: 1-800-422-4453 (1-800-4-A-CHILD), 24/7, for advice and connection to local reporting.
• If a child tells you: stay calm, listen, believe them, tell them it is not their fault, do not ask leading questions or promise secrecy, and report promptly.

Teachers, health workers, social workers and other professionals are mandated reporters in all US states.

Effects of abuse

Child abuse can have lasting effects on physical and mental health. Survivors have higher rates of post-traumatic stress disorder, depression, anxiety, substance use, chronic illness and relationship difficulties. These are adverse childhood experiences (ACEs). Early safety, stable relationships and trauma-focused therapy such as trauma-focused CBT greatly improve outcomes.

Prevention

• support for parents: home visiting programs, parenting classes and help with stress
• planning for crying: babies cry, sometimes for hours; it is safe to put a baby down in a safe crib and walk away for a few minutes to calm down
• safe, trusted childcare
• teaching children body safety and that they can tell a trusted adult
• community support, economic support for families, and access to mental health and substance use treatment

Frequently asked questions

What are the signs of child abuse?

Signs include unexplained injuries, bruises on babies who cannot yet cruise, patterned marks or burns, injuries that do not match the explanation, sudden behavior changes, fearfulness, sexual knowledge inappropriate for age, and signs of neglect such as hunger and poor hygiene.

What are the four main types of child abuse?

The four main types are neglect, physical abuse, sexual abuse and emotional abuse. Neglect is the most commonly reported. Many children experience more than one type.

How do I report child abuse?

If a child is in immediate danger, call 911. Otherwise, contact your state or local child protective services, or call the Childhelp National Child Abuse Hotline at 1-800-422-4453 for guidance. You only need a reasonable suspicion, not proof.

Is a bruise on a baby a sign of abuse?

Bruises are very uncommon in babies who are not yet pulling to stand or cruising. Any bruise in a young baby needs prompt medical evaluation, both to check for abuse and to rule out medical causes such as bleeding disorders.