When asked to describe their most difficult cases, many nurses put child-abuse cases at the top of their list. Most of us can deal (intellectually, at least) with the ravages of cancer or the deterioration that comes with aging. Child maltreatment can be much harder to cope with emotionally.

As much as we may wish for a world without child abuse, we still continue to see its ugly marks nearly every day. As a nurse, you play a key role in handling child abuse cases, both in your professional role and as a member of the community. The greater your insight into the clinical and legal aspects of child maltreatment, the greater your ability to meet the challenges these difficult cases can pose.

The term child abuse encompasses a broad spectrum of maltreatment, including physical abuse, sexual abuse, and neglect. Understanding the three general clinical concepts below will help you care for abused children more effectively.

Concept #1: Bruises on babies are nearly always bad.

Everyone understands that children get bruises. But as pediatric and forensic nurses know, an unexplained bruise in a nonambulatory child isn’t the same as an unexplained bruise in a 2-year old. Nonambulatory infants (those who can’t move on their own) get bruises only from external sources.

Although accidents do happen, the parent or other caregiver should be able to reasonably explain any bruise on an infant’s body. A child with an unexplained bruise deserves a full child-abuse workup. If you see bruising in a nonambulatory child, be suspicious and refer the child for further workup. Coagulation studies and a skeletal survey can yield more information.

Be aware that for an infant with normal blood clotting, the usual activities of daily living shouldn’t cause a bruise. So if the infant you’re examining doesn’t have a clotting disorder and the injury isn’t consistent with the parent’s explanation, consider the possibility of an inflicted injury (unless an accident can be identified). Bruises on the soft tissue of the body, ears, neck, and trunk should raise the greatest suspicion of child abuse. If you note a bruise, the child must undergo a complete skin exam to check for other injuries.

Every infant with a bruise needs a careful assessment, which should include skeletal imaging (a bone scan or skeletal survey) and coagulation studies. In many cases, the workup also includes a computed tomography (CT) scan and a retinal examination—screening tools that may reveal more evidence of abuse. For example, if you find bruising on the abdomen, the infant should have a CT scan to explore for an intra-abdominal injury.

Commonly, though, radiologic and blood tests show normal results, revealing no specific mechanism for the child’s condition. When this occurs, you play a key role in deciding how an abuse investigation should proceed while continuing to rule out the possibility of a medical condition. A child abuse specialist should always be part of the multidisciplinary team of physicians, nurse practitioners, social workers, radiologists, and child protective services staff that investigates every suspected child abuse case.

Keep in mind that normal findings for the skeletal survey and other studies don’t necessarily rule out abuse. A decision on how the case should proceed should be made by an experienced interdisciplinary team of care providers.

Concept #2: Consider a possible head injury in an infant with vomiting, irritability, and lethargy.

Over the past few years, we’ve learned that inflicted traumatic brain injury in infants is a diverse spectrum, of which “shaken baby syndrome” is just one aspect. Infants are sensitive to forces applied to the head. The most dramatic and severe injuries are easiest to identify; for instance, after a blow from a hammer, an infant who was smiling and happy one moment may be comatose the next.

But an infant with an insidious onset of such symptoms as vomiting, irritability, and lethargy poses a much greater challenge. In young infants, these findings can have many possible causes—but inflicted head injury is high on the list. In many cases, a vomiting, irritable infant is misdiagnosed with the flu or gastroenteritis when in fact she has a head injury. Several studies, including my own, show that healthcare personnel may miss head injury in infants. For example, up to one-third of infants diagnosed as having been shaken show some evidence of a previous head injury; vomiting could represent onset of a head injury that has gone undetected. These are important facts to consider when evaluating an infant for a possible head injury.

A full workup for an infant with a suspected inflicted traumatic brain injury includes CT and magnetic resonance imaging (MRI) scans of the head, a skeletal survey, appropriate blood work, and a retinal exam by an ophthalmologist.

Concept #3: Most prepubertal children who’ve been molested have normal exam findings.

Any child who discloses a history of sexual abuse should undergo a medical exam. The purpose of the exam isn’t just to reveal medical findings; it’s also to reassure the victim and her family that she’s normal and not “damaged for life.”

About 85% to 95% of prepubescent children who disclose sexual abuse have normal exam findings. Yet normal findings don’t rule out sexual abuse, because many types of sexual abuse (such as fondling and oral sex) don’t cause physical findings. Also, many children don’t disclose sexual abuse until days to weeks after it has occurred, giving the injuries time to heal. Even significant trauma can heal in a few days without scars.

Thus, if a police officer or protective worker asks you after you’ve completed an exam on a child, “Has she been molested?” your response should be, “We don’t know yet.” That’s because to answer this question, you need to know the history of the case and what, if anything, the child has disclosed. It’s all about the history. A good forensic interview and complete investigation must be done.

Cultures for sexually transmitted diseases (STDs) commonly are taken during the exam. Although most children with STDs have symptoms, this isn’t always the case, so it’s best to obtain cultures on any child who discloses sexual abuse.

Approach to the clinical examination

The clinical exam is a crucial part of the healing process; when done appropriately, it’s rarely traumatic for the child. “Done appropriately” means done by experienced personnel who specialize in this type of examination—preferably at an advocacy center or other center specializing in child sexual abuse. (See the inset below.)

Specialized child-abuse advocacy center
Specialized child-abuse advocacy centers provide a safe haven for the child to be interviewed and examined by a multidisciplinary team of experts. These centers bring together professionals equipped to help the abused child through this traumatic time. Such an environment helps ensure privacy, reduces the risk of undue trauma to the victim, and provides the highest level of expertise.

Child-abuse advocacy centers typically use a multidisciplinary team consisting of a forensic nurse, a nurse practitioner, a physician who is an expert in child abuse, a social worker, intake coordinators, on-call legal aid, and a director. They also have a connection to a women’s shelter. In addition, police officers are available; an assigned officer is best. Personnel are trained in interacting with trauma victims during both the acute and chronic phases. The exam room is nonthreatening. A separate room with a warm, homelike environment is used for interviewing the child.

Of course, a child with acute injuries and bleeding must be cared for right away at the closest medical facility. In prepubescent children, though, acute injuries from sexual abuse are rare. More commonly, the victim discloses he or she was molested at some time in the past.

Helping the victim cope with emotional repercussions

Keep in mind that children who’ve been sexually abused have endured tremendous emotional distress, which they’re not capable of understanding. Whatever their developmental and chronological ages, children generally lack the analytical ability to work through these overwhelming feelings. What’s more, emotional abuse goes hand in hand with physical abuse. Both the emotional wounds and physical wounds need time to heal.

When dealing with an abused child, always try to build a trusting and secure relationship. Keep in mind that the child needs empathy, not sympathy. While working with the child and family, try not to seem shocked or upset; instead, use a kind, empathetic approach. As you gain more experience dealing with traumatized children and families, this will be easier.

Building trust

To build trust, show sensitivity to the child. For example, if the child doesn’t wish to talk about the abuse, respect those boundaries. The child will open up in his or her own time.

Recognize, too, that abused children want to feel you believe them. So reassure them you’re there to help them and you believe what they’re saying. Abused children also feel they’ve done something wrong and deserved to be abused, so let them know there’s nothing wrong with them and that under no circumstances did they deserve the abuse.
Also realize that most abused children feel conflicted and confused about the abuser, especially if that person was a parent or someone else the child knew and trusted. Explain to the child that abuse is abnormal. Studies show most children love the parent who abused them, even though they fear and hate the abuse.

The child, family, or other caregiver should get professional counseling to help them deal with these complex issues. The physical scars of abuse heal eventually, but emotional pain can wreak havoc for a lifetime if not properly treated. Be sure to assess and document the child’s emotional status. (See the inset below.)

A nurse’s touch makes all the difference
A 10-year old child was kidnapped on her way to school and molested by a 50-year-old man. When she arrived at our clinic by ambulance, she was in shock—and alone; her mother couldn’t be located. The emergency medical technicians rushed her into the clinic, reported her vital signs and what had happened to her, and then left.

I knew the girl was terrified, so I sat next to her and tried to talk to her, but she remained silent. There was a lot of commotion in the room as we prepared a sexual assault kit for her. I sat by her side for nearly 20 minutes, but she still wouldn’t talk. She didn’t want to interact with us.

Then I started to think of her as if she were my own child. I realized she needed to feel safe, so I turned to her and wrapped my arms around her and told her she was safe now. She began to sob. She wanted her mother. She wouldn’t let go of me. All she wanted was to know she was safe and we were there to protect her. Finally, she started telling me about school and her family. I held her hand as much as I could during the exam. I gave her more hugs than I could count.

The rest of the exam went well; she even laughed once or twice. Although she was traumatized by the incident, I was able to create a special bond with her by hugging like her own mother would have. I realized I had to make her feel safe and cared for.

Reporting child abuse

Your role as a nurse extends to the legal realm, because nurses are mandated reporters of child abuse. Without knowledgeable reporters of alleged child abuse, an important link in child safety is destroyed, placing thousands of children at risk.

The Child Abuse Prevention and Treatment Act gives federal funds to states that comply with minimum guidelines. Each state has its own child-abuse reporting statutes, as well as the discretion to make its child-abuse laws stricter than federal laws. For example, each state has its own legal definition of child abuse, mandated reporters of child abuse, circumstances in which the state can intervene, where to send the report, and role that civil (family or juvenile) court and criminal court play. Procedural aspects of a case are covered under the state’s specific codes, too. A family may have to appear in both civil and criminal court for the same alleged incident.

As a mandated reporter of child abuse, you must ensure an accurate report of the abuse—not just to protect the child but to safeguard your own professional and personal status. You may be liable to civil charges if you fail to report suspected child abuse—especially if significant harm comes to the child due to your failure to act. Know that a person who reports suspected child abuse in good faith retains absolute immunity from civil or criminal liability. On the other hand, a report made in bad faith (false reporting) is subject to the state’s false reporting laws.

Become familiar with your state’s child abuse law so you know how to report an alleged case of child abuse correctly. Each state has a child abuse hotline to report suspected child abuse and neglect. To find state reporting numbers, state websites, and the correct reporting agency, visit www.childwelfare.gov; this website lists pertinent information for each state and Puerto Rico. Be aware that some state hotlines may not operate 24 hours a day. However, Childhelp® operates a national child abuse hotline 24 hours a day, 7 days a week, at 1-800-4-A-CHILD.

Most state laws guarantee anonymity to the reporter. But as a nurse, you have a duty to report suspected child abuse whether or not you’re covered by anonymity. For most nurses and other healthcare workers, the employer may have an institutional policy to follow when reporting suspected child abuse.

Be aware that recent case law indicates that simply reporting your concerns to a supervisor doesn’t always satisfy the law. In the recent case, a person reported suspected abuse to a supervisor; the supervisor didn’t follow through by sending a report to social services, deciding instead to handle the situation internally. Both the supervisor and the initial reporter were convicted of a crime. So if you suspect abuse, follow your institution’s policy—but also make sure to personally make a report to the appropriate reporting agency. If this isn’t part of your hospital’s policy, have a discussion with the risk management department about revisiting the policy.

Child abuse is a HIPAA exception

Be aware that reporting suspected child abuse is an exception under the confidentiality rules of the Health Insurance Portability and Accountability Act (HIPAA). If you suspect child abuse, you must disclose any pertinent information in the patient’s medical record to the appropriate reporting agency as required by law. When you do this, you’re not breaching the HIPAA privacy rule.

Nursing offers many rewards and many challenges. Nowhere are we challenged more than in the area of child abuse. By gaining the knowledge and tools to enhance your clinical expertise and advocacy skills, you can make a tremendous difference in a child’s life.

Selected references

Adams J. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat. 2001;6(1):31-36.

Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics. 2007;119(6):1232-4.

Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents: “Normal” does not mean “nothing happened.” Pediatrics. 2004;113(1):E67-E69.

Lazoritz S, Palusci V., eds. The Shaken Baby Syndrome: A Multidisciplinary Approach. Haworth Press; 2002.

U.S. Department of Health & Human Services. Child Maltreatment 2008. www.acf.hhs.gov/programs/cb/pubs/cm08/index.htm. Accessed April 15, 2010.

U.S. Department of Health & Human Services. Child Welfare Information Gateway. www.childwelfare.gov. Accessed April 15, 2010.

Stephen Lazoritz is a clinical professor in the Department of Psychiatry at Creighton University School of Medicine in Omaha, Nebraska. Katherine Rossiter is an adjunct faculty member in the Department of Nursing at Olivet Nazarene University in Bourbonnais, Illinois. Dina Whiteaker is on the staff at Project Harmony, a nonprofit agency in Omaha that aids child abuse victims.