Clinicians must always consider physical abuse when a child shows bruises or injuries that cannot be adequately explained or that are incompatible with the history that the parent gives. Suspicious physical indicators are bruises and marks that form symmetrical patterns, such as injuries to both sides of the face and regular patterns on the back, buttocks, and thighs; accidental injuries are unlikely to result in symmetrical patterns. Bruises may have the shape of the instrument used to make them, such as a belt buckle or a cord. Burns by cigarettes result in symmetrical, round scars, and immersions in boiling water produce burns that look like socks or gloves or that are doughnut shaped. Physical aggression can cause multiple and spiral fractures, especially in a young baby; retinal hemorrhages in an infant may result from shaking.

Children repeatedly brought to hospitals for treatment of peculiar or puzzling problems by overly cooperative parents may be victims of Munchausen’s syndrome by proxy, that is, factitious disorder. In this abuse scenario, a parent repeatedly inflicts illness on, or causes injury to, a child—by injecting toxins or by inducing the child to ingest drugs or toxins to cause diarrhea, dehydration, or other symptoms—and then eagerly seeks medical attention. Because the pathological parents are stealthy and superficially compliant, this is a difficult diagnosis to make.

In hospital emergency rooms, severely abused children show external evidence of body trauma, bruises, abrasions, cuts, lacerations, burns, soft tissue swellings, and hematomas. Hypernatremic dehydration, after periodic water deprivation of children by mothers who are usually psychotic, is another form of child abuse. Inability to move certain extremities because of dislocations and fractures associated with neurological signs of intracranial damage can also indicate inflicted trauma. Other clinical signs and symptoms attributed to inflicted abuse may include injury to the viscera. Abdominal trauma can result in unexplained ruptures of the stomach, the bowel, the liver, or the pancreas, with manifestations of an injured abdomen. Children with the most severe maltreatment injuries arrive at the hospital or physician’s office in a coma or in convulsions; some arrive dead.

Behaviorally, abused children may appear withdrawn and frightened or may show aggressive behavior and labile mood. They often exhibit depression, poor self-esteem, and anxiety. They may try physically to cover up injuries and are usually reticent to disclose the abuse for fear of retaliation. Abused children often show some delay in developmental milestones; they may have difficulties with peer relationships and may engage in self-destructive or suicidal behaviors.

Adults within the immediate or extended family of a child perpetrate most child sexual abuse. Thus, children commonly know the sexual abuser, who is often a highly trusted family member with a position of authority and with wide access to the child. Most cases of sexual abuse involving children are never revealed because of the victim’s feelings of guilt, shame, ignorance, and tolerance, compounded by some physicians’ reluctance to recognize and report sexual abuse, the court’s insistence on strict rules of evidence, and families’ fears of dissolution if the sexual abuse is discovered. Despite their familial roles, sexual abusers often threaten to hurt, kill, or abandon the children if the events are disclosed.

The incidence of sexual abuse and of child pornography, which is a form of sexual abuse, is much higher than had been previously assumed. Children may be sexually abused as early as infancy and as late as adolescence. Sexual abuse has been reported in schools, day care centers, and group homes, where adult caretakers are the major offenders.

The overwhelming fear, shame, and guilt that contribute to a child’s reticence to disclose sexual abuse also complicate identifying the abuse. Most often, no definitive physical evidence can prove the occurrence of sexual abuse. Physical indicators of sexual abuse include bruises, pain, and itching in the genital region. Genital or rectal bleeding may be a sign of sexual molestation. Recurrent urinary tract infections and vaginal discharges may be related to abuse. Sexually transmitted diseases and difficulty walking and sitting raise suspicions of sexual abuse.

No specific behavioral manifestations prove that sexual abuse has taken place, but children may exhibit many possible significant behaviors. Young children who have a detailed knowledge of sexual acts have usually witnessed or participated in sexual behavior. Young sexually abused children often exhibit their sexual knowledge through play and may initiate sexual behaviors with their peers. Aggressive behavior is common among abused children. Children who are extremely fearful of adults, particularly men, may have been subjected to sexual abuse. Clinicians should listen carefully to children who report sexual assaults even when parts of their stories are not consistent. When a child begins to disclose information about sexual assaults, retractions and contradictions are typical, and anxiety may prevent full disclosure.

The diagnosis of sexual abuse in children is full of pitfalls. An estimated 2 to 8 percent of allegations of sexual abuse are false. A much higher percentage of reports cannot be substantiated. Many investigations are done hastily or are carried out by inexperienced evaluators. In custody cases, an allegation of sexual abuse can be a maneuver to limit a parent’s visitation rights. Alleged sexual abuse of a pre-school-aged child is particularly difficult to evaluate because of the child’s immature cognitive and language development. The use of anatomically correct dolls has grown in popularity but is controversial. Patient and careful evaluations by experienced, objective professionals are necessary, and leading questions must be avoided. Children younger than the age of 3 years are unlikely to produce a verbal memory of past trauma or abuses,
but their experience may be reflected in play or fantasies. Some abused children meet the DSM-IV-TR diagnostic criteria for posttraumatic stress disorder (PTSD).

No specific psychiatric symptom results universally from sexual abuse. Vulnerability to the sequelae of sexual abuse depends on the type of abuse, its chronicity, the age of the child, and the overall relationship of the victim and the abuser. The psychological and physical effects of sexual abuse can be devastating and long lasting. Children who are sexually stimulated by an adult feel anxiety and overexcitement, lose confidence in themselves, and become mistrustful of adults. Seduction, incest, and rape are important predisposing factors to later symptom formations, such as phobias, anxiety, and depression. Abused children tend to be hyperalert to external aggression as shown by an inability to deal with their aggressive impulses toward others or with others’ hostility directed toward them.

Depressive feelings, usually combined with shame, guilt, and a sense of permanent damage, are commonly reported among children who have been sexually abused. Adolescents who have undergone sexual abuse are said to show high rates of poor impulse control and self-destructive and suicidal behaviors. PTSD and dissociative disorders are common in adults who have been sexually abused as children. Sexual abuse is a common preexisting factor in the development of dissociative identity disorder (also known as multiple personality disorder). Signs of dissociation include periods in which the children are amnestic, do not feel the pain, or feel that they are somewhere else. Borderline personality disorder has been reported in some patients with histories of sexual abuse. Substance abuse has also been reported with high frequency among adolescents and adults who were sexually abused as children.