Physical child abuse or non-accidental child trauma refers to fractures and other signs of injury that occur when a child is hit in anger.

The physical signs of child abuse used to be called battered child syndrome. This syndrome referred to many fractures that occurred at different times in children too young to have received them from an accident. The definition of child abuse has since been expanded.

See also:

• Child sexual abuse
• Child psychological abuse and neglect
• Shaken baby syndrome

Physical abuse tends to occur at moments of great stress. Many people who commit physical abuse were abused themselves as children. As a result, they often do not realize that abuse is not appropriate discipline.

Often people who commit physical abuse also have poor impulse control. This prevents them from thinking about what happens as a result of their actions.

The rate of child abuse is fairly high. The most common form is neglect.

The major risk factors for child abuse include:

• Alcoholism
• Drug abuse
• Being a single parent
• Lack of education
• Poverty

However, it is important to note that cases of child abuse are found in every racial or ethnic background and social class. It is impossible to tell abusers from non-abusers by looking at their appearance or background.

An adult may bring an injured child to an emergency room with a strange explanation of the cause of the injury. The child's injury may not be recent.

Symptoms include:

• Black eyes
• Broken bones that are unusual and unexplained
• Bruise marks shaped like hands, fingers, or objects (such as a belt)
• Bruises in areas where normal childhood activities would not usually result in bruising
• Bulging fontanelle
• Burn (scalding) marks
• Burns from an electric stove, radiator, heater or other hot objects, usually seen on the child's hands, arms or buttocks
• Choke marks around the neck
• Cigarette burns on exposed areas or on the genitals
• Circular marks around the wrists or ankles (signs of twisting or tying up)
• Human bite marks
• Lash marks
• Separated sutures
• Unexplained unconsciousness in an infant

Typical injuries in abused children include:

• Any fracture in an infant too young to walk or crawl
• Bleeding in the back of the eye, seen with shaken baby syndrome or a direct blow to the head
• Evidence of fractures at the tip of long bones or spiral-type fractures that result from twisting
• Evidence of skull fracture
• Fractured ribs, especially in the back
• Internal damage, such as bleeding or rupture of an organ from blunt trauma
• Multiple bruises that occured at different times -- especially in unusual areas of the body or in patterns that suggest choking, twisting, or severe beating with objects or hands
• Other unusual skin damage, including burns or burn scars
• Collection of blood in the brain (subdural hematoma) without good explanation

The following tests can reveal physical injuries:

• Bone x-ray. All the child's bones, including the skull, are x-rayed to look for unseen fractures or old, healing fractures.
• MRI or CT scan of the head or abdomen are done if there is a skull fracture, bleeding in the eye, unexplained vomiting, severe bruising of the face, skull or abdomen, unexplained nervous system (neurological) symptoms, headaches, or loss of consciousness.

The following medical conditions have symptoms similar to those of physical abuse:

• Osteogenesis imperfecta - almost all children with this condition have an abnormal (blue) coloring of the whites of the eyes. These children may have spontaneous fractures or break bones after accidents that would not harm the bones of a normal child.
• Undetected bleeding disorders such as hemophilia, Von Willebrand's disease, or liver disease can lead to abnormal bruising patterns. The doctor can test for these disorders.
• Unusual bruising and scarring patterns can also be caused by folk medicine or Oriental medicine practices such as coin rubbing, cupping, and burning herbs on the skin over acupuncture points (called moxibustion). The doctor should always ask about alternative healing practices.

The physical injuries are treated as appropriate.

The parents will need counseling or an intervention of some type. In some cases, the child may be temporarily or permanently removed from the home to prevent further danger. Life-threatening abuse, or abuse resulting in permanent damage to the infant or child may result in legal action.

Counseling, including play therapy, is also necessary for abused children over age 2. The child will need help dealing with the fear and pain of abuse caused by adults, who should be trusted figures. Failing to get this help can lead to significant psychological problems, such as post traumatic stress disorder (PTSD).

The appropriate government agency usually makes decisions about placing the child with an outside caregiver or returning the child to the home. This is typically done through the court system. The structure of these agencies varies from state to state.

Support groups are available for survivors of abuse and for abusive parents who want to get help. See the resource page for contact information.

The child's physical recovery depends on the severity of the injuries. Psychological recovery depends on the results of therapy, and whether the child can develop trusting relationships with adult caregivers.

The authorities will determine whether the abuser gets psychiatric help, such as parenting training and impulse/anger management training.

Child protection agencies generally make every effort to reunite families when possible.

Because adults are so much stronger and bigger than children, an abused child can be severely injured or killed by accident. Physical abuse of a child can lead to severe brain damage, disfigurement, blindness, crippling, and death. Abused individuals may carry emotional scars for a lifetime.

Children can be permanently removed from the parents' custody if the parents are abusive enough. However, this experience can also cause the child psychological problems. The child may feel rejected, or the placement may not lead to a strong, long-term attachment to the new caregivers.

All states require that you report any known or suspected child abuse. Call your health care provider, Child Protective Services, or local police if you suspect or know that someone is being abused.

Recognize the warning signs of abuse. The caregiver may:

• Have alcohol or drug problems
• Have a history of abuse or was abused as a child
• Have emotional problems or mental illness
• Have high stress factors, including poverty
• Not look after the child's hygiene or care
• Not seem to love or have concern for the child

Counseling or parenting classes may prevent abuse when any of these factors are present. Watchful guidance and support from the extended family, friends, clergy, or other supportive persons may prevent abuse or allow early intervention in cases of abuse.

Johnson CF. Abuse and neglect of children. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 36.