Signs and Symptoms of Abuse - Additional Information
and Symptoms of Abuse
1. Signs and Symptoms of Child Neglect
This category of abuse
is the most common. A distinction can be made between
'willful' neglect and 'circumstantial' neglect. For
instance, 'willful' neglect would generally incorporate a
direct and deliberate deprivation by a parent or caregiver
of a child's most basic needs e.g. withdrawal of food,
shelter, warmth, clothing, contact with others. Whereas
'circumstantial' neglect more often may be due to
stress/inability to cope by parents or caregiver. Neglect is
closely correlated with low socio-economic factors and
corresponding physical deprivations. It is also related to
parental incapacity due to learning disability or
psychological deprivations. It is also related to parental
incapacity due to learning disability or psychological
The neglect of
children is 'usually a passive form of abuse involving
omission rather than acts of commission'. It comprises 'both
a lack of physical caretaking and supervision and a failure
to fulfill the developmental needs of the child in terms of
[* Skuse, D. and Bentovim, A.
(1994) “Physical and Emotional Maltreatment”. In Rutter, M.
and Hersor, L. (Editors), Child and Adolescent Psychiatry
(Third Edition), Oxford:
Blackwell Scientific Publications.]
Child neglect should be
suspected in cases of:
Abandonment or desertion
Children persistently being
left alone without adequate care and supervision
food, inappropriate food or erratic feeding
Lack of warmth
Lack of adequate clothing
Lack of protection and
exposure to danger including moral danger or lack of
supervision appropriate to the child's age
Persistent failure to
Non-organic failure to
thrive i.e. child not gaining weight not alone due to
malnutrition but also due to emotional deprivation
Failure to provide adequate
care for the child's medical problems
2. Signs and Symptoms of Emotional Child Abuse
Emotional abuse occurs when adults responsible for taking
care of children are unable to be aware of and meet their
children's emotional and developmental needs. Emotional
abuse is not easy to recognize because the effects are not
easily observable. 'Emotional abuse refers to the habitual
verbal harassment of a child by disparagement, criticism,
threat and ridicule and the inversion of love; whereby
verbal and non-verbal means of rejection and withdrawal are
** Skuse D. (1989)
“Emotional Abuse and Neglect” in Meadow, R. “ABC of Child
Abuse”, British Medical Journal Publications, London.
Emotional abuse can be
defined in reference to the following indices. However, it
should be noted that no one indicator is conclusive of
Lack of praise and
Lack of comfort and love
Lack of attachment
Lack of proper stimulation
(e.g. fun and play)
Lack of continuity of care
(e.g. frequent moves)
punishment (e.g. locking in bedrooms)
Family conflicts and/or
Every child who is abused
sexually, physically or neglected is also emotionally
of a child's behavior - relative to his/her age and stage
3. Signs and Symptoms of Physical Abuse
explanations or varying explanations for the following
events are highly suspicious:
Bruises (see below for more
Burns and Scalds (see below
for more detail)
Abrasions and Lacerations
Damage to body organs
Poisonings - repeated
(prescribed drugs, alcohol)
Failure to thrive
There are many different
forms of physical abuse but skin, mouth and bone injuries
are the most common.
Bruises - in general
Accidental bruises are
common at places on the body where bone is fairly close to
the skin. Bruises can also be found towards the front of the
body, as the child usually will fall forwards.
Accidental bruises are common
on the chin, nose, forehead, elbow, knees and shins. An
accident-prone child can have frequent bruises in these
areas. Such bruises will be diffuse with no definite edges.
Any bruising on a child before the age of mobility must be
treated with concern.
Bruises are more
likely to occur on soft tissues e.g. cheek, buttocks, lower
back, back or thighs and calves, neck, genitalia and mouth.
Bruises - non-accidental
Marks from slapping or
grabbing may form a distinctive pattern. Slap marks might
occur on buttocks or cheeks and the outlining of fingers may
be seen on any part of the body. Bruises may be associated
with shaking which can cause serious hidden bleeding and
bruising inside the skull.
Any bruising around the neck
is suspicious as it is very unlikely to be accidentally
acquired. Bruises caused by direct blows with a fist have no
definite pattern but may occur in parts of the body which do
not usually receive injuries by accident. A punch over the
eye (black eye syndrome) or ear would be of concern.
Black eyes cannot be caused
by a fall onto a flat surface.
Two black eyes require
two injuries and must always be suspect.
Other injuries may feature -
ruptured eardrum or fractured skull. Mouth injury may be a
cause of concern - torn mouth (frenulum) from forced
bottle-feeding. Other distinctive patterns of bruising may
be left by the use of straps, belts, sticks and feet. The
outline of the object may be left on the child in a bruise
on areas such as back, thighs (areas covered by clothing).
Burns - in general
Children who have
accidental burns usually have a hot liquid splashed on them
by spilling or have come into contact with a hot object. The
history that parents give is usually in keeping with the
pattern of injury observed. However, repeated episodes may
suggest inadequate care and attention to safety within the
Burns - non-accidental
Children who have
received non-accidental burns may exhibit a pattern that is
not adequately explained by parents. The child may have been
immersed in a hot liquid. The burn may show a definite line,
unlike the type seen in accidental splashing. The child may
also have been held against a hot object like a radiator or
a ring of a cooker leaving distinctive marks. Cigarette
burns may result in multiple small lesions in places on the
skin that would not generally be exposed to danger. There
may be other skin conditions that can cause similar patterns
and expert pediatric advice should be sought.
Bites - in general
Children can get
bitten either by animals or humans. Animal bites, e.g. dogs
- commonly puncture and tear the skin and usually the
history is definite. Small children can also bite other
Bites - non accidental
It is sometimes hard
to differentiate between adults' and children’s' bites as
measurements can be inaccurate. Any suspected adult bite
mark must be taken very seriously. Consultant Pediatricians
may liaise with Dental colleagues in order to correctly
Bone injuries - in general
have accidents that result in fractures. However, children's
bones are more flexible than those of adults and the
children themselves are lighter, so a fracture, particularly
of the skull, usually signifies that considerable force has
Bone injuries - non-accidental
A fracture of any sort
should be regarded as suspicious in a child under 8 months
of age. A fracture of the skull must be regarded as
particularly suspicious in a child under 3 years. Either
case requires careful investigation as to the circumstances
in which the fracture occurred. Swelling in the head or
drowsiness may also indicate injury.
Poisoning - in general
Children may commonly
take medicines or chemicals that are dangerous and
potentially life threatening. Aspects of care and safety
within the home need to be considered with each event.
Poisoning - non-accidental
poisoning can occur and may be difficult to identify but
should be suspected in bizarre or recurrent episodes and
when more than one child is involved. Drowsiness or
hyperventilation may be a symptom.
Shaking is a frequent
cause of brain damage in very young children.
4. Signs and Symptoms of Child Sexual Abuse
Child sexual abuse
often covers a wide spectrum of abusive activities. It
rarely involves just a single incident and usually occurs
over a number of years. Child sexual abuse frequently
happens within the family. Intra-familial abuse is
particularly complex and difficult to deal with.
Cases of sexual abuse
principally come to light through:
disclosure by the child or
the suspicions of an adult;
due to physical symptoms.
Colburn Faller* provides a description of the
wide spectrum of activities
by adults which can constitute child sexual abuse.
Non contact sexual abuse
'Offensive Sexual Remarks'
including statements the offender makes to the child
regarding the child's sexual attributes, what he or she
would like to do to the child and other sexual comments.
involving the offender showing the victim his or her
private parts or masturbating in front of the victim.
instances when the offender observes the victim in a state
of undress or in activities that provide the offender with
sexual gratification. These may include activities that
others do not regard as even remotely sexually
involving any touching of
the intimate body parts. The offender may fondle or
masturbate the victim and/or get the victim to fondle
and/or masturbate them. Fondling can be either outside or
inside clothes. Also includes 'frottage', i.e. where
offender gains sexual gratification from rubbing his/her
genitals against the victim's body or clothing.
Oral-genital sexual abuse
offender licking, kissing, sucking or biting the child's
genitals or inducing the child to do the same to them.
Penetrative sexual abuse of which there are four types
involving putting fingers in the vagina, or anus or both.
Usually the victim is penetrated by the offender, but
sometimes the offender gets the child to penetrate them.
'penetration with objects'
involving penetration of the vagina, anus or occasionally
mouth with an object.
involving the penis entering the vagina, sometimes
involving the penis penetrating the anus.
[*Colbourn Faller, K.
(1989) “Child Sexual Abuse”. An Interdisciplinary Manual for
Diagnosis Case Management and Treatment. Basingstoke:
Involves situations of
sexual victimization where the person who is responsible
for the exploitation may not have direct sexual contact
with the child. Two types of this abuse are child
pornography and child prostitution.
includes still photography, videos and movies and, more
recently computer generated pornography.
'Child Prostitution' for
the most part involves children of latency age or in
adolescence. However, children as young as four and five
are known to be abused in this way.
Sexual abuse in combination
with other abuse.
The sexual abuses described
above may be found in combination with other abuses, such
as physical abuse and urination and defecation on the
victim. In some cases physical abuse is an integral part
of the sexual abuse; in others drugs and alcohol may be
given to the victim.
It is important to note that
physical signs may not be evident in cases of sexual abuse
due to the nature of the abuse or the fact that the
disclosure was made some time after the abuse took place.
Caregivers and professionals
should be alert to the following physical and behavioral
Bleeding from the vagina or
Difficulty or pain in
passing urine or feces
An infection may occur
secondary to sexual abuse, which may or may not be a
definitive sexually transmitted disease. Professionals
should be informed if a child has a persistent vaginal
discharge or has warts or rash in genital area.
uncharacteristic change of behavior
Hints about sexual activity
Age - inappropriate
understanding of sexual behavior
behavior with others
play with peers or toys
Unusual reluctance to join
in normal activities which involve undressing, e.g. games
Particular behavioral signs
and emotional problems suggestive of child abuse in young
Mood change, e.g. child
becomes withdrawn, fearful, acting out
Lack of concentration
(change in school performance)
Bed wetting, soiling
Nightmares, changes in
Loss of appetite
Particular behavioral signs
and emotional problems suggestive of child abuse in older
(10 yrs +):
Mood change, e.g.
depression, failure to communicate
Drug, alcohol, solvent
Note: All signs and
indicators need careful assessment relative to
the child's circumstances