Challenges and innovations in diagnosing nonphysical child abuse in pediatric emergency departments
Article information
Abstract
Child abuse is a widespread global health crisis with longterm implications for children’s physical, psychological, and emotional well-being. Pediatric emergency departments (PEDs) are often the first point of contact for children experiencing abuse, presenting unique diagnostic challenges due to the diverse manifestations of maltreatment. In contrast to physical abuse that often leaves visible markers, nonphysical abuse (e.g., emotional neglect or psychological harm) frequently go undetected, exacerbating underreporting and delayed interventions. This article examines the prevalence, diagnostic challenges, and multidisciplinary strategies for addressing child maltreatment in PEDs. Cultural and systemic barriers, coupled with insufficient training and resource constraints, hinder the recognition of subtle signs of nonphysical abuse. Advances in diagnostic imaging, behavioral assessment tools, and laboratory investigations are discussed as critical components of comprehensive evaluations. Multidisciplinary teams play a pivotal role in addressing the complexity of abuse cases, combining medical, psychological, and legal expertise to provide holistic care while minimizing additional trauma. The integration of artificial intelligence into diagnostic workflows is explored as a transformative innovation, offering potential for early detection of abuse patterns and enhanced decision-making. However, the implementation of artificial intelligence requires careful consideration to ensure that it complements human expertise and aligns with ethical standards. There is a need for standardized protocols, targeted training programs, and supportive systems to empower healthcare professionals in recognizing and reporting all forms of child maltreatment. We propose more research to develop tools capable of detecting nonphysical abuse in PEDs. By combining technological advancements, multidisciplinary collaboration, and educational initiatives, PEDs can improve outcomes for vulnerable children and address the widespread issue of child maltreatment more effectively.
Introduction
Child abuse is a pervasive global health crisis, leading to profound and often long-lasting physical, psychological, or emotional consequences (1). In pediatric emergency departments (PEDs), diagnosing child maltreatment presents unique challenges due to its wide array of manifestations, ranging from overt physical injuries to more subtle forms like emotional neglect or psychological maltreatment (2). The World Health Organization defines child maltreatment as any form of physical, psychological, or sexual abuse, as well as neglect or exploitation of children within relationships of trust or authority (1). In developed countries, abusive head trauma is the second most common cause of death in children under 1 year, often resulting from motor vehicle accidents, falls, or sports injuries (3).
One of the primary challenges in diagnosing child maltreatment is distinguishing between accidental injuries and those resulting from intentional harm. Injuries caused by abuse often present inconsistencies between the child’s injury and the caregiver’s explanation. For example, injuries like spiral or multiple fractures at various stages of healing should raise suspicions of abuse, as they are commonly associated with non-accidental trauma (4).
Pediatric emergency physicians (PEPs) are often the first point of contact for children experiencing abuse. However, they face obstacles in differentiating between accidental and intentional injuries, particularly in case of abuse without visible signs. The ability to detect and intervene in the cases is critical, as children often arrive in PEDs with injuries that may be misattributed to accidents or other causes, resulting in missed opportunities for intervention.
It is widely believed that nonphysical abuse does not have as much impact on children as physical abuse (5), but studies have shown that all forms of child maltreatment have equal ramifications for the health of the child (5-7). Hence, it is important that PEPs be aware of presenting signs of nonphysical abuse and be able to advocate for the patients given the implications (5).
Physical abuse generally manifests with visible injuries such as bruises, fractures, or burns, which are easier to detect during emergency evaluations (2). However, nonphysical abuse, such as emotional neglect and psychological harm, poses substantial diagnostic challenges. These forms of maltreatment often present as behavioral changes, such as anxiety, depression, or developmental delays, rather than visible signs of trauma (8). The absence of immediate physical markers makes diagnosing nonphysical abuse particularly difficult in fast-paced PEDs (4).
Main subject
1. Prevalence and impact of child abuse in PEDs
Child abuse, particularly in its nonphysical forms, remains underreported worldwide. In the United States alone, approximately 2,000,000 reports of child maltreatment are filed annually, but only half are substantiated (4). The invisibility of nonphysical abuse often leads to underreporting, particularly in busy PEDs where staff are not trained to recognize the more subtle forms of abuse (8). Available information shows that the prevalence of nonphysical abuse is greater than physical or sexual abuse. A global study during the coronavirus disease 2019 pandemic shows an estimated prevalence of physical child maltreatment of 18% and that of psychological abuse of 39% (9). In Canada, over 30% of individuals reported experiencing nonphysical abuse in childhood, while 4.1% reported being physically abused. Additionally, 23% reported experiencing both physical and nonphysical abuse (10).
Cultural attitudes and societal norms can further complicate the recognition and reporting of child maltreatment. In many cultures, disciplinary practices that involve physical punishment or emotional manipulation may be considered acceptable, making it difficult for healthcare providers to distinguish abuse from cultural practices (11). These cultural barriers often result in underreporting of nonphysical forms of abuse, which are less understood and harder to substantiate than physical abuse.
Furthermore, the legal and societal frameworks surrounding child protection vary widely across countries, with some nations prioritizing physical abuse over nonphysical forms due to the challenges of quantifying emotional harm. This results in a systematic underestimation of the true scope of child maltreatment, particularly in low- and middle-income countries, where access to resources and child protection services is often limited (12).
The prevalence of child maltreatment has operational implications for PEDs. Staff members are frequently overwhelmed by the sheer volume of cases (4,11). The complex, multifactorial nature of child maltreatment exacerbates the difficulty in identifying nonphysical forms of abuse (4,13). In many cases, PEPs may focus on treating acute physical injuries, potentially overlooking the more insidious psychological harm that often accompanies abuse.
Additionally, PEPs may lack confidence in their ability to identify and report nonphysical abuse due to the absence of training in recognizing emotional and psychological trauma (14). This further perpetuates the underreporting of nonphysical child abuse, with long-term consequences for the child’s wellbeing (11).
2. Diagnostic approaches in physical and nonphysical pediatric abuse cases
A thorough physical examination remains the cornerstone of the diagnostic process in case of suspected child maltreatment. Certain injury patterns, such as bruising in unusual locations (e.g., torso, ears, or neck) or fractures inconsistent with the reported history, should raise immediate suspicion of abuse (15,16). PEPs must be vigilant in noting signs of repetitive trauma, such as bruises at different stages of healing, which may indicate ongoing abuse.
Imaging is an essential diagnostic tool for confirming suspicions of abuse, particularly in case of abusive head trauma or suspected skeletal fractures (17). Computed tomography, magnetic resonance imaging, bedside ultrasound, and skeletal surveys are often employed to detect subdural hematomas, brain swelling, or fractures in various stages of healing (17,18). Computed tomography is particularly useful in identifying acute head injuries, while magnetic resonance imaging provides more detailed imaging of the brain parenchyma or soft tissues (17). Recent studies have demonstrated the utility of bedside ultrasound, particularly in detecting occult injuries such as periosteal hematomas in case of suspected child abuse, which might otherwise go unnoticed during a physical examination (18,19).
In case of nonphysical abuse, behavioral changes often serve as primary indicators of maltreatment. Emotional withdrawal, extreme fear of caregivers, and developmental regression may be signs of ongoing abuse (20). Like physical abuse, nonphysical abuse has been found to be associated with depression, anxiety, eating disorders, substance use, and suicidal behavior (21). Given that research has shown that all forms of abuse have the same long-term outcomes for children (5,21,22), PEPs should be able to identify subtle signs of psychological trauma and nonphysical abuse, which may be otherwise overlooked in the absence of physical injury.
Behavioral assessment tools, such as the Strengths and Difficulties Questionnaire (SDQ) and Child Behavior Checklist (CBCL), can play key roles in evaluating behavioral changes commonly associated with abuse. Abnormal behavioral changes can be categorized as “internalizing (inward-focused)”or “externalizing (outward-focused)”behavioral problems. The internalizing behaviors are focused on the own self, such as withdrawal, anxiety, depression, shyness, hypersensitivity, and somatic complaints. In contrast, the externalizing behaviors manifest outwardly during social interactions and may include aggression, impulsivity, and other uncontrolled behaviors (23,24). These 2 behavioral problems are interlinked, yet it is useful to examine the internalizing behaviors independently from the externalizing counterparts in order to better understand their unique contributors. The internalizing behaviors are more indicative of children’s psychological and emotional state (24), and hence more likely to be the presenting signs of child maltreatment (23). These internalizing or externalizing behavioral changes are associated with unfavorable development outcomes, including poor academic performance, antisocial behavior, delinquency, peer problems, and poor mental health in adulthood (24,25). Research has shown a smaller contribution of genetic factors to these behavioral disorders than previously thought, showing an increased role of ignored factors like nonphysical abuse in contributing to these disorders (26).
PEPs can make more use of tools like the SDQ and CBCL to screen for mental health problems in children or adolescents in PEDs. The SDQ is the most widely used research instrument related to the mental health of children and early to mid-adolescents (27). Its internalizing and externalizing scales have been demonstrated to remain largely independent of each other (28). The SDQ also has a self-report version for 11-16 years of age, can be filled by guardians or teachers, and is shorter and often preferred by caregivers (29). The CBCL is designed to obtain data on behavioral or emotional problems and competencies, and is designed to be filled in by the guardians (30).
Identifying physical and sexual abuse has been primarily focused on the available validated screening tools for child abuse, such as the SPUTOVAMO (a mnemonic-based screening tool designed to assess physical and sexual abuse indicators), SCAN (a more recent validated brief tool designed to improve early recognition of child maltreatment in the emergency department), and ESCAPE (a 6-question screening instrument for child abuse in the emergency department) (31-33). While effective in their scope, these tools often overlook nonphysical abuse (31-33). The tools contain components including reasons for visit, consistent medical history, injuries incompatible with the history or developmental level of the child, delay in seeking medical help, interaction of the child with the guardians, and physical examination findings (31). Among these components, only the “interaction of the child with the guardians”can potentially capture behavioral changes seen in nonphysical child abuse.
Unlike the abovementioned tools, the SDQ emphasizes identifying emotional and behavioral indicators, making it suitable for detecting nonphysical abuse. We recommend adapting the SDQ to develop a screening version that can be used in PEDs to help identify children who suffer from nonphysical abuse. Given the high validation and widespread use of SDQ in pediatric populations (27,29), adapting it for nonphysical abuse detection is more time- and cost-efficient, compared to developing a new tool from scratch. In the meantime, PEPs can familiarize themselves with some of the questions which are components of the SDQ, and use them in cases highly suspicious of emotional child abuse. There are examples of SDQ-derived questions that can quickly give a glimpse into the emotional state of a child including (34): “Is your child often unhappy, down-hearted, or tearful?”“Does your child have at least one good friend?”“Does your child often lie or cheat?” and “Does your child have many fears and is easily scared?”These questions can be asked directly to children aged 11 years or older and are components of the 25-item SDQ (29,34). To overcome the possible barrier of time constraints, this tool can be administered by allied staff members in the PED.
Laboratory tests can provide crucial evidence of child abuse if used in conjunction with clinical contexts although they cannot confirm abuse on their own (35). For example, assays for hemoglobin, electrolytes, or vitamins can help identify signs of malnutrition or neglect (36). High concentrations of aminotransferases may suggest abdominal trauma, while vitamin D deficiencies could indicate chronic neglect. Laboratory tests can also be used to detect exposure to drugs or toxic substances and help differentiate child abuse from other diagnoses (35).
3. Multidisciplinary approaches and ethical considerations in child abuse diagnosis
The complexity of abuse cases often requires the collaboration of multidisciplinary teams (MDTs), which include pediatricians, social workers, mental health professionals, and legal authorities (37). Table 1 summarizes the roles of different members of an MDT in child abuse detection (38,39). MDTs play a critical role in diagnosing and managing abuse by combining their expertise in different areas to provide comprehensive care for the child (39,40). They work to ensure a successful conclusion to abuse investigations and to minimize additional trauma to the victim (41).
Roles of multidisciplinary teams in child abuse detection
Multidisciplinary approaches were initially developed to improve coordination and collaboration among various professionals and institutions, such as law enforcement, social services, healthcare, and legal systems, to ensure a more effective and cohesive response to sexual abuse. Over time, MDTs have expanded their scope to encompass abuse and neglect, enabling them to investigate cases of suspected nonphysical abuse (42). This suggests that PEPs working in busy PEDs can refer suspected cases of nonphysical abuse to MDTs. However, this process may not always work, as physicians often differ in their definitions of abuse and there remains a prevalent belief that nonphysical abuse causes less harm to children compared to physical and sexual abuse (5).
Studies have shown the effectiveness of a multidisciplinary approach to abuse. MDTs reduce the fragmentation of service delivery systems and ensure that children and families receive the help they need at the end (43). Members of an MDT play key roles and work together to ensure good outcomes (38). For instance, forensic pathologists and radiologists are essential in identifying patterns of injury that may be indicative of non-accidental trauma, while mental health professionals assess the child’s psychological well-being and provide support for emotional recovery (38,39).
Healthcare providers often face ethical and practical challenges when diagnosing suspected child maltreatment. The primary concern is to protect the child from further harm, but diagnostic uncertainty can complicate decision-making. PEPs are legally mandated to report any reasonable suspicion of abuse, even when the evidence is ambiguous in certain countries like the U.S. and Canada (44,45). However, healthcare professionals or mandatory reporters are sometimes hesitant to report suspected abuse due to various barriers, such as unfamiliarity with the reporting process, lack of training in recognizing abuse signs, concerns about damaging relationships with families, fear of legal repercussions, and concerns about personal safety (45-47). These barriers can lead to underreporting, which may leave children at continued risk of harm.
To address these challenges, several strategies can be employed. Clear and standardized hospital protocols for managing suspected abuse cases, coupled with multidisciplinary involvement and legal consultations, are essential in ensuring both the child’s safety and the family’s rights are protected (48). In addition, targeted training programs for healthcare professionals can improve their diagnostic confidence and familiarity with mandatory reporting procedures (46). Efforts to reduce workload-related barriers, such as streamlined reporting processes and support from child protection teams, may also encourage timely reporting (46). Lastly, fostering a supportive work environment that prioritizes the psychological safety and well-being of reporters can help address personal concerns and hesitations (45).
4. Innovations and future directions in child abuse detection
Artificial intelligence (AI) is transforming diagnostic approaches in PEDs. AI tools have a unique capability to analyze large datasets and identify patterns, hence one of the most purported ways where AI could revolutionize healthcare is by analyzing patterns within subsets of population who present similar clinical phenotypes (49). That is, the AI tools can be particularly valuable in the context of child maltreatment, where pattern recognition is critical (50,51). AI algorithms can assist pediatricians in recognizing patterns of injury consistent with abuse, such as subdural hematoma or retinal hemorrhage on imaging (52), as well as historical data indicative of emotional abuse or neglect which can be captured on patients’electronic health records (49,53). Additionally, AI can incorporate social and environmental factors as data points to flag potential cases of child maltreatment, including nonphysical forms of maltreatment (54,55). Researchers have applied machine learning to electronic health records to generate personalized medicine by incorporating patient data into risk predictors (56).
The application of AI and machine learning can enable PEPs to make quicker, more accurate decisions about which children require further assessment (50,55). As AI tools become more integrated into clinical workflows, they are expected to enhance diagnostic efficiency and reduce the likelihood of overlooking abuse cases (50). However, it is essential to establish robust guidelines for AI use in abuse detection to ensure these technologies complement, rather than replace, human expertise (55).
Future research should focus on improving data surveillance through linked databases and standardizing definitions of child maltreatment across regions. Such initiatives can support the development of machine learning algorithms designed to detect abuse more effectively (51). By integrating data from multiple sources, including healthcare records, social services, and educational institutions, researchers can better track maltreatment cases and identify key risk factors (57). In addition to leveraging AI, improving healthcare providers’training in recognizing nonphysical abuse remains critical. PED staff should be equipped with screening tools that detect subtle signs of emotional neglect or psychological trauma alongside traditional diagnostic methods as discussed earlier.
Conclusion
A multidisciplinary approach that integrates advanced diagnostic tools, ethical decision-making, and technological innovations is essential for improving the detection and management of child abuse in PEDs. Behavioral assessment tools, such as the SDQ and CBCL, can help PEPs quickly check for signs consistent with mental health challenges, which are usually the only pointers in nonphysical abuse. AI may play a key role in enhancing diagnostic accuracy, while MDTs involving social workers, mental health professionals, and legal authorities will help ensure that children receive comprehensive, compassionate care.
Notes
Conflicts of interest
No potential conflicts of interest relevant to this article were reported.
Funding sources
No funding source relevant to this article was reported.
Author contributions
Conceptualization and Validation: MA and CDO
Methodology: CDO
Resources: CDO, MA, and MMA
Writing-original draft: MA and CDO
Writing-review and editing: all authors
All authors read and approved the final manuscript.