Step 2 CK · Family & Preventive Medicine

Abuse, Neglect & Family Violence

Name: Abuse, Neglect & Family Violence
Creator: Veli Bakalov, MD

Recognize inflicted injury and know exactly when reporting is mandatory

Family & Preventive Medicine·Preventive Medicine·5 min read·9 high-yield points·Reviewed by Veli Bakalov, MD @HemeOncBuddy

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Report child abuse (CPS) and elder or vulnerable-adult abuse (APS) on reasonable suspicion; proof is not required, good-faith reporters are immune, and failure to report is a crime.
Most specific fractures for abuse: posterior rib fractures (chest squeezing) and classic metaphyseal corner/bucket-handle fractures (shaking); multiple fractures of different ages suggest repeated trauma.
Any long-bone fracture or bruise in a non-ambulatory infant is a red flag, while a spiral tibia (toddler's fracture) in a walking child is usually accidental.
Abusive head trauma: multilayered retinal hemorrhages + subdural hematoma (bridging veins) ± diffuse axonal injury, often without external signs → fundoscopy and head CT.
Workup of suspected physical abuse: skeletal survey under age 2 (repeat in ~2 weeks), CBC and coagulation studies to exclude bleeding disorders.
Immersion burns: sharp waterline, stocking/glove pattern, spared flexion creases and buttocks; TEN-4 bruising (torso, ear, neck at ≤4 years, or any bruise at ≤4 months) is suspicious.
Neglect is the most common form of child maltreatment (failure to thrive, dental caries, missed immunizations).
IPV in a competent adult is usually not reportable: screen women of reproductive age, validate, document, safety-plan, and give resources; homicide risk peaks at separation.
Sexual assault: SANE exam, emergency contraception, ceftriaxone + doxycycline + metronidazole, HIV PEP within 72 hours, hepatitis B vaccination; Munchausen by proxy is reportable child abuse.

The reporting framework

Suspicion, not proof. Physicians are mandated reporters of child abuse and neglect and of elder or dependent-adult abuse. The threshold is reasonable suspicion: report to Child Protective Services (CPS) or Adult Protective Services (APS) without waiting for proof, confronting the family, or gaining consent. Reporters acting in good faith are legally immune, and failure to report is a crime.

Mandatory versus confidential

Situation	Report?	What to do
Child abuse or neglect	Mandatory	Report to CPS on suspicion; ensure the child's safety
Elder or vulnerable-adult abuse	Mandatory	Report to APS on suspicion
Factitious disorder imposed on another	Mandatory	Report as child abuse
Gunshot, stab, or other violent injuries	Often mandatory	Follow state law, even for competent adults
IPV against a competent adult	Not mandated in most states	Keep it confidential; support, safety-plan, refer
Adult sexual assault	The patient's choice	Offer care and forensic exam; the patient decides about police

Child physical abuse: recognizing inflicted injury

Developmental stage is everything. Always ask whether the history is plausible for the child's mobility. In a non-ambulatory infant (not yet cruising or walking), any long-bone fracture and any bruise is suspicious: "those who don't cruise rarely bruise." A spiral fracture from twisting is worrisome in an infant, whereas a spiral tibia ("toddler's fracture") and shin bruises are usually accidental in a walking child. Other red flags are a delay in seeking care, a changing or vague story, and a mechanism that does not match the injury.

Fractures. The most specific for abuse are posterior rib fractures, from squeezing the chest, which levers the ribs against the spine. CPR and short falls do not cause them. Classic metaphyseal lesions (corner or bucket-handle fractures) come from shaking or yanking a limb. Scapular, sternal, and spinous-process fractures are also highly specific, and multiple fractures at different stages of healing suggest repeated trauma.

Accidental versus inflicted patterns

Injury	Usually accidental	Suggests abuse
Fractures	Toddler's spiral tibia, clavicle, distal radius buckle in a mobile child	Posterior ribs, metaphyseal corner fractures, scapula, sternum, spinous processes; any long-bone fracture in a pre-walker
Burns	Splash or spill: irregular margins, satellite drops, variable depth	Immersion: sharp waterline, symmetric stocking or glove pattern, spared flexion creases and buttocks ("donut"); round ~8 mm deep cigarette burns
Bruises	Bony prominences (shins, forehead) in a walker	TEN-4 regions or any bruise in a young infant; patterned bruises (hand, loop, belt)

TENtorso, ear, or neck bruising in a child age 4 or younger

≤4 monthsany bruise at all in an infant

Abusive head trauma (shaken baby). The triad is multilayered retinal hemorrhages extending to the periphery, subdural hematoma from torn bridging veins, and diffuse axonal injury. There are often no external signs. The infant presents with lethargy, irritability, vomiting, poor feeding, seizures, or apnea, which are easily mistaken for a viral illness. Severe retinal hemorrhages rarely follow accidental short falls.

Workup of suspected abuse, and neglect

Skeletal surveyIn every child under age 2 with suspected physical abuse; repeat in about 2 weeks to catch healing fractures that were occult at first.
Dilated fundoscopyBy ophthalmology, for retinal hemorrhages.
NeuroimagingNon-contrast head CT (MRI to follow) if abusive head trauma is suspected.
CBC and coagulation studiesTo exclude a bleeding disorder that mimics bruising.
Report and protectReport to CPS; evaluate siblings and other children in the home.

Suspected physical abuse

Mimics to exclude include osteogenesis imperfecta (blue sclerae, family history), bleeding disorders such as hemophilia and vitamin K deficiency, congenital dermal melanocytosis (slate-gray "Mongolian spots"), and cultural practices such as coining and cupping.

Neglect. Neglect is the most common form of child maltreatment: failure to provide food, shelter, supervision, medical or dental care, or education. Clues are failure to thrive, poor hygiene, severe dental caries, missed immunizations and appointments, and developmental delay. It is reportable just like physical abuse.

Elder abuse and intimate partner violence

Elder abuse. Forms include physical, emotional, and sexual abuse, financial exploitation, neglect, and abandonment. The key risk factors are cognitive impairment or dementia, functional dependence, social isolation, and caregiver stress or substance use. Most abusers are family members. Clues include unexplained bruises, poor hygiene, missed medications, and a caregiver who controls the patient's money. Report suspected cases to APS.

Tension buildingThe victim is "walking on eggshells."
Acute batteringAn explosive violent incident.
HoneymoonContrition and promises to change.
Cycle repeatsOften escalating over time.

The cycle of violence

IPV screening. Screen women of reproductive age (USPSTF grade B), interviewing the patient alone, with a professional interpreter if needed, never the partner or a family member. Pregnancy can trigger or escalate violence. Suspect IPV with injuries inconsistent with the story, a delay in presentation, repeated visits, or a partner who will not leave the room.

Management in a competent adult. In most states, do not report to police. Respect autonomy while you validate the disclosure, document injuries (the patient's own words, body diagrams), assess immediate safety, build a safety plan, and offer resources such as the National Domestic Violence Hotline (1-800-799-SAFE).

Do not pressure the patient to leave: homicide risk peaks at separation. Injuries from firearms or knives are separately reportable in many states, even in competent adults.

Sexual assault and factitious disorder imposed on another

Sexual assault care. Ensure safety and treat injuries, then offer a forensic exam by a Sexual Assault Nurse Examiner (SANE) with an intact chain of custody. The patient decides whether to involve police: a forensic exam does not require a police report, and evidence can be collected up to about 120 hours (5 days) after the assault. Offer:

Emergency contraception (after a pregnancy test); it works better the sooner it is given
Empiric STI prophylaxis: ceftriaxone plus doxycycline plus metronidazole
HIV post-exposure prophylaxis, which must start within 72 hours
Hepatitis B vaccination, plus counseling and follow-up testing

Factitious disorder imposed on another (Munchausen by proxy). A caregiver, usually a parent, fabricates or induces illness in a child to assume the sick role by proxy; there is no external reward such as money. Clues are recurrent unexplained illness, symptoms that appear only when the caregiver is present and resolve on separation, and an overly attentive, medically savvy parent who pushes for more tests. Example: hypoglycemia with high insulin and low C-peptide points to injected exogenous insulin. This is child abuse and must be reported.