Child Physical Abuse: An Overview
Barbara H. Chaiyachati, MD, PhD, Cindy W. Christian, MD
University of Pennsylvania, USA
The social environment in which children live has a profound effect on their health and well-being. For children around the globe, few social problems cause greater harm to their health than child abuse and neglect. Regardless of the type of maltreatment perpetrated against a child, the potential for lifelong physical and emotional consequences is significant.1 Although seemingly straightforward, the definition of physical abuse is variable. Child physical abuse has been defined by the World Health Organization as the intentional use of physical force against a child that results or has a high likelihood of resulting in harm for the child’s health, survival, development or dignity.2 Legal definitions of physical abuse typically require physical harm to have occurred; governmental definitions of abuse and neglect are not uniform. Some definitions of physical abuse do not include perpetrator intent; others reflect motive rather than injury type.3 Additionally, definitions of physical abuse are culturally determined, and what is considered abusive in one society may not be in another.4,5 In many societies, physical violence against children as a method of punishment is endorsed by parents, sanctioned by societal institutions (such as schools) and allowed by law.
Quantifying the burden of child physical abuse is difficult. In addition to the definitional challenges, in many countries, epidemiologic data are not collected, and in those countries that monitor child maltreatment, official reports do not reflect the true prevalence.6-8 Measuring physical abuse is methodologically challenging, and incidence and prevalence will vary by the surveillance methods used to define and detect the problem.9 Many maltreated children are not brought to the attention of public agencies, and are not counted in official statistics. Even when abused children are brought to the attention of health or child welfare professionals, the abuse may be unrecognized or ignored by those in a position to protect the child.10,11 Review of the best available research estimates that global prevalence of maltreatment by self-report is 226/1,000 children and approximately 125/1,000 for American children.12,13 Lifetime risk of confirmed maltreatment for American children is estimated to be greater than 1 in 10.14
Child abuse results from a complex interaction of individual, family and societal risk factors. A number of variables are traditionally thought to increase the risk for child physical abuse. These include poverty, substance abuse, single parenthood, household composition, young maternal age, parental depression or other mental illness, and exposure to intimate partner violence.15-20 A risk factor may impact families independently or risk factors may accumulate toward a threshold increased risk for physical abuse.21 Risk factors for specific types of physical abuse have also been documented. For example, men more commonly perpetrate abusive head trauma, and rates of fatal child abuse are exceptionally high for young children who live in households with an unrelated adult in the home.22,23 Although the association of some of these risk factors and child maltreatment is clear, risk factors should be considered broadly defined markers, rather than strong individual determinants of abuse. Understanding the epidemiology of child abuse is important for developing governmental policies and intervention and prevention strategies. However, the individual professional cannot rely on population-based risk factors in determining whether a child before him or her is a victim of physical abuse.
Consequences of Child Physical Abuse
Victims of abuse are at high risk for poor health, related not only to the physical trauma they have endured, but also to high rates of other social risk factors associated with poor health.24 Abused children have high rates of growth problems, untreated vision and dental problems, infectious diseases, developmental delay, mental health and behavioural problems, early and risky sexual behaviours, and chronic illnesses, but child welfare and health care systems historically have not addressed the health needs of dependent children.25-30 Compared to children in foster care, maltreated children who remain at home exhibit similarly high rates of physical, developmental and mental health needs.31
Child physical abuse takes many forms, and patterns and severity of injury vary by age of the child. Although physical abuse is more common among older children, the youngest victims ̶ infants and toddlers ̶ have the highest rates of mortality from physical abuse.32 They are the most vulnerable because of their physical and developmental immaturity, and relative social invisibility.2 Morbidity from physical abuse is high in young victims of physical abuse, reflecting both the physical consequences of trauma to the small child and the developmental and emotional effects of early childhood trauma on the developing brain.
The public health consequences of child physical abuse are sizeable, and extend into adulthood. Retrospective and prospective studies have identified strong associations between cumulative traumatic childhood events, such as child maltreatment and family dysfunction, and adult physical disease, such as heart disease, liver disease, autoimmune diseases, sexually transmitted infections, and early death.33-37 Mental health disease and the use of psychotropic medications are also greater in adults who had been maltreated as children.38-40
Scientific investigation is improving our understanding of the causal biological pathways for these robust associations.41 Early childhood trauma, including physical abuse, leads to the production of stress hormones, such as cortisol and adrenaline that are normally protective, but with severe or persistent trauma can become toxic.42,43 These stress hormones regulate neural circuits that are important in modulating an individual’s response to stress, and over time, are associated with structural and functional changes in the brain and other organs. Influenced further by epigenomes, these changes are linked with impairment in the child’s ability to respond to future biological and environmental stress, and increase the risk for physical and mental health disease later in life.44,45 This research underscores the need to develop and test prevention and early intervention strategies for children who have been victims of serious physical abuse.
Recognition of Physical Abuse
Injuries that result from abuse are not always obvious or diagnostic, and identifying child physical abuse can be challenging. The history provided by the parent or other responsible adult may be inaccurate, either because the adult is unaware of the actual history, or is unwilling to provide a truthful history. There are many potential barriers to providing a truthful history that may include circumstances when the caregiver is the perpetrator of intentional abuse, the caregiver is fearful of consequences related to a plausible accident, or the caregiver is fearful for their own safety with regard to disclosing abuse by another adult. Victims of serious physical abuse are often too young or too ill to provide a history of their assault, and if older, may be too frightened to do so. Injuries to non-ambulatory infants, those that are not explained by the reported history, multiple or patterned injuries, and injuries to multiple organ systems should always raise the possibility of abuse. Abusive injuries to children are most commonly found on the skin, but the most serious injuries occur to the brain, abdomen and other internal organs.46,47 No single injury is diagnostic of abuse, but certain patterns of trauma can be highly specific for maltreatment. It is important to recognize that there is a differential diagnosis for every potential injury, and objective and thorough evaluation is required in order to identify abuse with reasonable confidence.48,49
Implications for Policy
Child physical abuse is a pervasive social problem. Child welfare agencies in the U.S. receive more than four million reports of suspected maltreatment annually and investigate approximately two-thirds of the reports made.32,50 At any given time, more than 400,000 American children reside in foster care.51 Despite the documented direct effects of physical abuse on the health of children, the recognition that early childhood trauma is a leading predictor of adult morbidity and early mortality, and the enormous indirect costs of funding the social and legal systems required to investigate abuse, protect children, hold perpetrators accountable and treat affected families, available public resources struggle to adequately address the problem.52
Child welfare services are historically structured as short-term interventions that monitor families for recidivism, provide targeted parenting education and assist with referrals to community-based services. The focus is on prevention of abuse recurrence, with less emphasis on prevention of child and family impairment, all of which are important measures of outcome. Little research has addressed treatment to improve children’s impairment after physical abuse, but a few programs, such as Parent-Child Interaction Therapy, have shown promise in preventing the recurrence of child physical abuse.53,54
The argument for primary prevention and early identification and treatment is compelling, but children have no political capital, and solutions require comprehensive programs with collaboration between child welfare, law enforcement, courts, health and education. The evidence-base for child abuse prevention is growing yet there are still limited rigorous studies that show significant impact.55-57 Programs that show promise are discussed in the Child Maltreatment Prevention paper by Professor Jane Barlow.58
Preventing the physical abuse of children and protecting them from further harm continues to require a public health approach. Reducing rates of maltreatment, supporting struggling families and improving pediatric and adult outcomes for victims requires community-wide strategies, with collaboration between child welfare, judicial, education, health and mental health colleagues to advocate for programs that are adequately tested and shown to be effective. Finally, reducing the toll of child abuse will only come when policy-makers embrace the belief that an ounce of prevention is truly better than a pound of cure.
- Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine. 1998;14(4):245-258.
- Butchart A, Phinney Harvey A, Mian M, Furniss T, Kahane T. Preventing child maltreatment: a guide to taking action and generating evidence. Geneva: World Health Organization; 2006.
- Southall DP, Samuels MP, Golden MH. Classification of child abuse by motive and degree rather than type of injury. Archives of Disease in Childhood. 2003;88(2):101-104.
- Runyan DK, Shankar V, Hassan F, et al. International variations in harsh child discipline. Pediatrics. 2010;126(3):e701-711.
- Maker AH, Shah PV, Agha Z. Child physical abuse: prevalence, characteristics, predictors, and beliefs about parent-child violence in South Asian, Middle Eastern, East Asian, and Latina women in the United States. Journal of Interpersonal Violence. 2005;20(11):1406-1428.
- Theodore AD, Chang JJ, Runyan DK, Hunter WM, Bangdiwala SI, Agans R. Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics. 2005;115(3):e331-337.
- Herman-Giddens ME, Brown G, Verbiest S, et al. Underascertainment of child abuse mortality in the United States. JAMA. 1999;282(5):463-467.
- Schnitzer PG, Covington TM, Wirtz SJ, Verhoek-Oftedahl W, Palusci VJ. Public health surveillance of fatal child maltreatment: analysis of 3 state programs. American Journal of Public Health. 2008;98(2):296-303.
- Keenan H, Leventhal J. The evolution of child abuse research. In: Reece RM, Christian C, eds. Child abuse: medical diagnosis and management. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009;1-18.
- Gilbert R, Kemp A, Thoburn J, et al. Recognising and responding to child maltreatment. Lancet. 2009;373(9658):167-180.
- Sege RD, Flaherty EG. Forty years later: inconsistencies in reporting of child abuse. Archives of disease in childhood. 2008;93(10):822-824.
- Stoltenborgh M, Bakermans-Kranenburg MJ, van Ijzendoorn MH, Alink LR. Cultural-geographical differences in the occurrence of child physical abuse? A meta-analysis of global prevalence. International Journal of Psychology. 2013;48(2):81-94.
- Finkelhor D, Ormrod R, Turner H, Hamby SL. The victimization of children and youth: a comprehensive, national survey. Child Maltreatment. 2005;10(1):5-25.
- Wildeman C, Emanuel N, Leventhal JM, Putnam-Hornstein E, Waldfogel J, Lee H. The prevalence of confirmed maltreatment among US children, 2004 to 2011. JAMA Pediatrics. 2014;168(8):706-713.
- Sedlak AJ, Mettenburg J, Basena M, Peta I, McPherson K, Greene A. Fourth national incidence study of child abuse and neglect (NIS-4). Washington, DC: US Department of Health and Human Services Retrieved on July. 2010;9:2010.
- Chaffin M, Kelleher K, Hollenberg J. Onset of physical abuse and neglect: Psychiatric, substance abuse, and social risk factors from prospective community data. Child Abuse & Neglect. 1996;20(3):191-203.
- Brown J, Cohen P, Johnson JG, Salzinger S. A longitudinal analysis of risk factors for child maltreatment: Findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse & Neglect. 1998;22(11):1065-1078.
- Walsh C, MacMillan HL, Jamieson E. The relationship between parental substance abuse and child maltreatment: findings from the Ontario Health Supplement. Child Abuse & Neglect. 2003;27(12):1409-1425.
- McGuigan WM, Pratt CC. The predictive impact of domestic violence on three types of child maltreatment. Child Abuse & Neglect. 2001;25(7):869-883.
- Rumm PD, Cummings P, Krauss MR, Bell MA, Rivara FP. Identified spouse abuse as a risk factor for child abuse1. Child Abuse & Neglect. 2000;24(11):1375-1381.
- Yang MY, Maguire‐Jack K. Individual and Cumulative Risks for Child Abuse and Neglect. Family Relations. 2018;67(2):287-301.
- Starling SP, Holden JR, Jenny C. Abusive head trauma: the relationship of perpetrators to their victims. Pediatrics. 1995;95(2):259-262.
- Schnitzer PG, Ewigman BG. Child deaths resulting from inflicted injuries: household risk factors and perpetrator characteristics. Pediatrics. 2005;116(5):e687-e693.
- Oh DL, Jerman P, Silverio Marques S, et al. Systematic review of pediatric health outcomes associated with childhood adversity. BMC Pediatrics. 2018;18(1):83.
- Deutsch SA, Fortin K. Physical Health Problems and Barriers to Optimal Health Care Among Children in Foster Care. Current Problems in Pediatric and Adolescent Health Care. 2015;45(10):286-291.
- Simms MD, Dubowitz H, Szilagyi MA. Health care needs of children in the foster care system. Pediatrics. 2000;106(Supplement 3):909-918.
- Jee SH, Barth RP, Szilagyi MA, Szilagyi PG, Aida M, Davis MM. Factors associated with chronic conditions among children in foster care. Journal of Health Care for the Poor and Underserved. 2006;17(2):328-341.
- Ahrens KR, Richardson LP, Courtney ME, McCarty C, Simoni J, Katon W. Laboratory-diagnosed sexually transmitted infections in former foster youth compared with peers. Pediatrics. 2010;126(1):e97-e103.
- Clausen JM, Landsverk J, Ganger W, Chadwick D, Litrownik A. Mental health problems of children in foster care. Journal of Child and Family Studies. 1998;7(3):283-296.
- Oswald SH, Heil K, Goldbeck L. History of maltreatment and mental health problems in foster children: A review of the literature. Journal of Pediatric Psychology. 2009;35(5):462-472.
- Leslie LK, Gordon JN, Meneken L, Premji K, Michelmore KL, Ganger W. The physical, developmental, and mental health needs of young children in child welfare by initial placement type. Journal of Developmental and Behavioral Pediatrics. 2005;26(3):177-185.
- U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2015. 2017. https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment. Accessed May 17, 2019.
- Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS medicine. 2012;9(11):e1001349.
- Chen E, Turiano NA, Mroczek DK, Miller GE. Association of reports of childhood abuse and all-cause mortality rates in women. JAMA Psychiatry. 2016;73(9):920-927.
- Dong M, Giles WH, Felitti VJ, et al. Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation. 2004;110(13):1761-1766.
- Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic Medicine. 2009;71(2):243-250.
- Dong M, Dube SR, Felitti VJ, Giles WH, Anda RF. Adverse childhood experiences and self-reported liver disease: new insights into the causal pathway. Archives of Internal Medicine. 2003;163(16):1949-1956.
- Lindert J, von Ehrenstein OS, Grashow R, Gal G, Braehler E, Weisskopf MG. Sexual and physical abuse in childhood is associated with depression and anxiety over the life course: systematic review and meta-analysis. International Journal of Public Health. 2014;59(2):359-372.
- Edwards V, Holden G, Anda R, Felitti V. Experiencing multiple forms of childhood maltreatment and adult mental health: results from the adverse childhood experiences (ACE) study. American Journal of Psychiatry. 2003;160(8):1453-1460.
- Anda RF, Brown DW, Felitti VJ, Bremner JD, Dube SR, Giles WH. Adverse childhood experiences and prescribed psychotropic medications in adults. American Journal of Preventive Medicine. 2007;32(5):389-394.
- Shonkoff JP, Garner AS, Siegel BS, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232-e246.
- McEwen BS. Protective and damaging effects of stress mediators. New England Journal of Medicine. 1998;338(3):171-179.
- McEwen BS. The neurobiology of stress: from serendipity to clinical relevance1. Brain Research. 2000;886(1-2):172-189.
- Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron. 2016;89(5):892-909.
- Gunnar MR, Fisher PA. Bringing basic research on early experience and stress neurobiology to bear on preventive interventions for neglected and maltreated children. Development and Psychopathology. 2006;18(3):651-677.
- Reece RM, Christian C, eds. Child Abuse Medical Diagnosis and Management, 3rd Ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
- Jenny C. Child abuse and neglect: Diagnosis, treatment and evidence [e-book]. Philadelphia: Elsevier Health Sciences; 2010.
- Christian CW, States LJ. Medical mimics of child abuse. American Journal of Roentgenology. 2017;208(5):982-990.
- Metz JB, Schwartz KA, Feldman KW, Lindberg DM. Non-cutaneous conditions clinicians might mistake for abuse. Archives of Disease in Childhood. 2014;99(9):817-823.
- Tumlin KC, Geen R. The decision to investigate: Understanding state child welfare screening policies and practices. New Federalism: Issues and Options for States. Series A, No. A-38. Assessing the new federalism: An urban institute program to assess changing social policies. 2000.
- Child Welfare Information Gateway. Foster care statistics 2017. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. 2019.
- Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect. 2012;36(2):156-165.
- Barlow J, Johnston I, Kendrick D, Polnay L, Stewart-Brown S. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews. 2006;3CD005463.
- Chaffin M, Silovsky JF, Funderburk B, et al. Parent-child interaction therapy with physically abusive parents: efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology. 2004;72(3):500-510.
- Fergusson DM, Grant H, Horwood LJ, Ridder EM. Randomized trial of the Early Start program of home visitation. Pediatrics. 2005;116(6):e803-e809.
- MacMillan HL, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. Interventions to prevent child maltreatment and associated impairment. Lancet. 2009;373(9659):250-266.
- Viswanathan M, Fraser JG, Pan H, et al. Primary care interventions to prevent child maltreatment: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;320(20):2129-2140.
- Barlow J. Prevention of Child Maltreatment and Associated Impairment. In: Tremblay RE, Boivin M, Peters RDeV, eds. MacMillan HL, topic ed. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/maltreatment-child/according-experts/prevention-child-maltreatment-and-associated-impairment. Published February 2012. Accessed April 16, 2019.
How to cite this article:
Chaiyachati BH, Christian CW. Child Physical Abuse: An Overview. In: Tremblay RE, Boivin M, Peters RDeV, eds. MacMillan HL, topic ed. Encyclopedia on Early Childhood Development [online]. https://www.child-encyclopedia.com/maltreatment-child/according-experts/child-physical-abuse-overview. Updated May 2019. Accessed April 11, 2021.