Child Abuse: Fractures in Abused Children

The National Child Abuse and Neglect System (NCANDS) of the Administration of Children, Youth, and Families (ACYF) Annual Report 2009 indicates that there were 9.3 unique abuse victims confirmed per 1,000 children in the United States. Children 1 year and younger had the highest rate of victimization; there was an almost equal distribution of boys and girls; some children experienced multiple abuses. Neglect was most frequent (78.3%), followed by physical abuse (17.8%). Sexual and psychologic maltreatment each occurred in 10% of abused children overall. The 2009 national fatality rate was 2.34 per 100,000 and has been increasing over the past 5 years. Health and mental health-care professionals should maintain the possibility of abuse on their differential every time they see a child.

Clinical Presentation. Presentations vary greatly depending on the type(s) of abuse as well as social and emotional developmental stage. Children with developmental disabilities, that is, mental retardation, emotional disturbances, visual or hearing impairment, learning disabilities, physical disabilities, behavior problems, or other medical problems are at increased risk of being victims.

Physical abuse most often manifests with signs of abuse, including bruising and/or skeletal injury. In addition, physical abuse is often associated with psychologic impacts, including increased anger, aggression, poor academic performance, sleep problems, drug abuse, and suicidality. Sexually abused children often present to physicians for evaluation of genital injury. The sequelae includes impaired mental health with increase in rates of depression, anxiety disorders, sleep disorders, suicide attempts, and posttraumatic disorder (PTSD), but not schizophrenia or somatoform disorders.

With psychologic abuse, it is more difficult to quantify and identify consistent patterns of presentation. Children of psychologic abuse present with increased levels of depression, academic difficulties, aggression, and behavior problems. Often, children are exposed to more than one type of abuse, and so the impact of abuse can be complex. In addition, physical, sexual, and psychologic abuse are associated with poor self-esteem, personality disorders, and impaired interpersonal relationships.

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